Basic Information
| Provider Information | |||||||||
| NPI: | 1497781462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OCCHINO | ||||||||
| FirstName: | FREDERICK | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OCCHINO | ||||||||
| OtherFirstName: | FREDERICK | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 517 SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | HAMBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140754231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166462590 | ||||||||
| FaxNumber: | 7166462593 | ||||||||
| Practice Location | |||||||||
| Address1: | 517 SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | HAMBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140754231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166462590 | ||||||||
| FaxNumber: | 7166462593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 01/11/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS11880 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | OS11880 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207Q00000X | 108941 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00593724 | 05 | NY | MEDICAID |