Active NPI
Theodore A Buccilli Jr., DPM
- Podiatrist
- Ravenna, OH
National Provider Identifier
1164413019
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Podiatrist
- License
- 36003352
- Practice address
- 4403 Clover Dr
Ravenna, OH 44266-8636 - Phone
- (330) 687-7464
- NPI assigned
- Oct 31, 2005
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Podiatrist | 213E00000X | 36003352 | OH | Primary |
Addresses
Primary practice location
4403 Clover Dr
Ravenna, OH 44266-8636
Mailing address
5500 Armstrong Rd
Battle Creek, MI 49037-7314
Phone (269) 966-5600
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 36003352 | OH | MD | Podiatrist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Hospice of Ohio, LLC | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Clinic/Center
- Youngstown, OH
- NPI 1396244562
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1130716800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1755216000000",
"number": "1164413019",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5500 ARMSTRONG RD",
"city": "BATTLE CREEK",
"state": "MI",
"postal_code": "490377314",
"telephone_number": "269-966-5600"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4403 CLOVER DR",
"city": "RAVENNA",
"state": "OH",
"postal_code": "442668636",
"telephone_number": "330-687-7464"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BUCCILLI",
"first_name": "THEODORE",
"middle_name": "A",
"name_prefix": "Dr.",
"name_suffix": "Jr.",
"credential": "DPM",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2005-10-31",
"last_updated": "2025-08-15",
"certification_date": "2025-08-15",
"status": "A"
},
"taxonomies": [
{
"code": "213E00000X",
"taxonomy_group": "",
"desc": "Podiatrist",
"state": "OH",
"license": "36003352",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Ravenna, OH
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 15, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.