Provider Demographics
NPI:1902893340
Name:GUCCIONE, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GUCCIONE
Suffix:
Gender:M
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:PO BOX 1042
Mailing Address - Street 2:PO BOX 1042
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-9042
Mailing Address - Country:US
Mailing Address - Phone:718-881-2100
Mailing Address - Fax:718-881-5164
Practice Address - Street 1:3322 BAINBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2849
Practice Address - Country:US
Practice Address - Phone:718-881-2100
Practice Address - Fax:718-881-5164
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211368174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02560850Medicaid
NY28Q811Medicare ID - Type Unspecified
NY02560850Medicaid