Provider Demographics
NPI:1306918339
Name:COLUCCI, ROBERT DANIEL (DO)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DANIEL
Last Name:COLUCCI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 DUNLAWTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4239
Mailing Address - Country:US
Mailing Address - Phone:386-763-1000
Mailing Address - Fax:
Practice Address - Street 1:285 CLYDE MORRIS BLVD STE 300
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8144
Practice Address - Country:US
Practice Address - Phone:239-690-6906
Practice Address - Fax:386-262-1628
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1999812084P0800X, 2084P0804X
FLOS180942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02916365Medicaid
NY02126507Medicaid
NY02916365Medicaid