Basic Information
| Provider Information | |||||||||
| NPI: | 1578514881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PUCCIONI | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 241353 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023989243 | ||||||||
| FaxNumber: | 4023989253 | ||||||||
| Practice Location | |||||||||
| Address1: | 8005 FARNAM DR | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023989243 | ||||||||
| FaxNumber: | 4023989253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 02/13/2008 | ||||||||
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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 | 207T00000X | 21012 | NE | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1540658 | 05 | IA | MEDICAID | 34166 | 01 | NE | BCBS | OTHER | 97943 | 01 | IA | BCBS | OTHER | 47061940513 | 05 | NE | MEDICAID |