Basic Information
| Provider Information | |||||||||
| NPI: | 1942237441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUCCILLO | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2120 | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998332120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077723975 | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 FRAM STREET | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998330589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077724299 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207QS0010X | AA2935 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.