Provider Demographics
NPI:1356427090
Name:PUCILLO FAMILY PRACTICE PA
Entity type:Organization
Organization Name:PUCILLO FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASPIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-340-9355
Mailing Address - Street 1:16659 SOUTHWEST FWY # 461
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-2375
Mailing Address - Country:US
Mailing Address - Phone:281-340-9355
Mailing Address - Fax:281-340-9366
Practice Address - Street 1:16659 SOUTHWEST FWY # 461
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2375
Practice Address - Country:US
Practice Address - Phone:281-340-9355
Practice Address - Fax:281-340-9366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00X530Medicare PIN
TXDF7789Medicare PIN