Basic Information
| Provider Information | |||||||||
| NPI: | 1659318061 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCCIOLA | ||||||||
| FirstName: | POMPEO | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 S EVERGREEN AVE | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080962739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566864300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 DIAMOND HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERKELEY HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079222104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082778601 | ||||||||
| FaxNumber: | 9082778706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
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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 | 208000000X | 25MA06931600 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7978107 | 05 | NJ | MEDICAID |