Basic Information
| Provider Information | |||||||||
| NPI: | 1114997939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROCACCINO | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 972 BRUSH HOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115901740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168765555 | ||||||||
| FaxNumber: | 5168765539 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 NORTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | GREAT NECK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110215302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167302100 | ||||||||
| FaxNumber: | 5167302121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 09/23/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 171315 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.