Provider Demographics
NPI:1114923422
Name:PEZZULICH, ROBERT ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ANTHONY
Last Name:PEZZULICH
Suffix:
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 1:88 MEADOW BROOK DR
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-9263
Mailing Address - Country:US
Mailing Address - Phone:802-447-7203
Mailing Address - Fax:
Practice Address - Street 1:345 ELM ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2265
Practice Address - Country:US
Practice Address - Phone:802-447-7591
Practice Address - Fax:802-447-3858
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0004872208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0004497Medicaid
VTB85459Medicare UPIN
VT0004497Medicaid