Provider Demographics
NPI:1528172079
Name:CATUCCI, CANDIDA (MD)
Entity type:Individual
Prefix:
First Name:CANDIDA
Middle Name:
Last Name:CATUCCI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4008 FORLEY ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1427
Mailing Address - Country:US
Mailing Address - Phone:718-565-6565
Mailing Address - Fax:718-565-6999
Practice Address - Street 1:4008 FORLEY ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1427
Practice Address - Country:US
Practice Address - Phone:718-565-6565
Practice Address - Fax:718-565-6999
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193213207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01511733Medicaid
F67543Medicare UPIN
NY04163Medicare ID - Type Unspecified