Basic Information
| Provider Information | |||||||||
| NPI: | 1689856999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELLUCCI | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 500 COMMACK RD UNIT 206 | ||||||||
| Address2: | |||||||||
| City: | COMMACK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117255022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316752125 | ||||||||
| FaxNumber: | 6316752628 | ||||||||
| Practice Location | |||||||||
| Address1: | 47 COMMERCE AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119013106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319787633 | ||||||||
| FaxNumber: | 6316384884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 249072 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 249072 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 249072 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.