Provider Demographics
NPI:1992981450
Name:MICUCCI, ANTHONY FRANCIS (DC)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:FRANCIS
Last Name:MICUCCI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 KETTLES LN
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1552
Mailing Address - Country:US
Mailing Address - Phone:631-834-7808
Mailing Address - Fax:
Practice Address - Street 1:170 KETTLES LN
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1552
Practice Address - Country:US
Practice Address - Phone:631-834-7808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006790-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor