Provider Demographics
NPI:1104843077
Name:PISANELLI, VICTOR J JR (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:J
Last Name:PISANELLI
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4560
Mailing Address - Country:US
Mailing Address - Phone:802-775-1904
Mailing Address - Fax:
Practice Address - Street 1:241 STRATTON RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4621
Practice Address - Country:US
Practice Address - Phone:802-775-1903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT42-0005978208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0004711Medicaid
VTC65222Medicare UPIN
VT0004711Medicaid