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Individual
MARK ANTHONY MICOLUCCI
Active
Individual
MARK ANTHONY MICOLUCCI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
52497
SC
390200000X
Student in an Organized Health Care Education/Training Program
LL52497
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
LL52497
STATE
SC
Enumeration date
06/15/2018
Last updated
08/31/2021
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