Provider Demographics
NPI:1023170750
Name:KEVIN A FUCIARELLI MD PC
Entity type:Organization
Organization Name:KEVIN A FUCIARELLI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FUCIARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-513-7047
Mailing Address - Street 1:23823 N 113TH PL
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-5637
Mailing Address - Country:US
Mailing Address - Phone:480-513-7047
Mailing Address - Fax:480-948-1727
Practice Address - Street 1:10615 N HAYDEN RD
Practice Address - Street 2:SUITE C 100-102
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-5734
Practice Address - Country:US
Practice Address - Phone:480-513-7047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-16
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29740207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ69677Medicare PIN