Provider Demographics
NPI:1871095893
Name:BUCCI, MARK J (CPO)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:BUCCI
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3361
Mailing Address - Country:US
Mailing Address - Phone:252-338-3002
Mailing Address - Fax:
Practice Address - Street 1:106 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3361
Practice Address - Country:US
Practice Address - Phone:252-338-3002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO005782222Z00000X
224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCPO04410OtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS, PROSTHETICS, & PEDORTHICS