Basic Information
| Provider Information | |||||||||
| NPI: | 1063424828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARRUCCIU | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 BELLE TERRE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117772316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314731320 | ||||||||
| FaxNumber: | 6316867626 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 N COUNTRY RD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117772119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314731320 | ||||||||
| FaxNumber: | 6314731320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 08/17/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 158313 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01018148 | 05 | NY | MEDICAID |