Provider Demographics
NPI:1114948643
Name:PANNULLO, DENNIS R (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:R
Last Name:PANNULLO
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:
Practice Address - Street 1:281 E HARTFORD AVE
Practice Address - Street 2:
Practice Address - City:UXBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01569-1278
Practice Address - Country:US
Practice Address - Phone:508-278-5573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50619207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000030217OtherBMC HEALTHNET
55332OtherFALLON
MAAA33669OtherHPHC
050619OtherTUFTS
5411703OtherCIGNA
406524OtherRI BLUE CHIP
MAJ02284OtherMABC
MAJ02284Medicare ID - Type Unspecified
000000030217OtherBMC HEALTHNET