1558853606 NPI number — DR. MICHAEL RICHARD PROCACCINI OD

Table of content: DR. MICHAEL RICHARD PROCACCINI OD (NPI 1558853606)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558853606 NPI number — DR. MICHAEL RICHARD PROCACCINI OD

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
PROCACCINI

Provider First Name:
MICHAEL

Provider Middle Name:
RICHARD

Provider Name Prefix Text:
DR.

Provider Name Suffix Text:

Provider Credential Text:
OD

Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:
PROCACCINI

Provider Other First Name:
MICH

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1558853606

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
03/30/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 OLD GALLOWS RD STE 520

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
VIENNA

Provider Business Mailing Address State Name:
VA

Provider Business Mailing Address Postal Code:
22182-3970

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
703-847-8899

Provider Business Mailing Address Fax Number:
571-223-6780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
370 DANIEL WEBSTER HWY

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
MERRIMACK

Provider Business Practice Location Address State Name:
NH

Provider Business Practice Location Address Postal Code:
03054-4152

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
603-424-0404

Provider Business Practice Location Address Fax Number:
603-424-1147

Provider Enumeration Date:
06/05/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 152W00000X , with the licence number: 0974 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .