Provider Demographics
NPI:1154481232
Name:DR. ALFRED J. IEZZI JR. PC
Entity Type:Organization
Organization Name:DR. ALFRED J. IEZZI JR. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:J
Authorized Official - Last Name:IEZZI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:609-335-8275
Mailing Address - Street 1:3101 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:LONGPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:08403-1436
Mailing Address - Country:US
Mailing Address - Phone:609-335-8275
Mailing Address - Fax:
Practice Address - Street 1:3101 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:LONGPORT
Practice Address - State:NJ
Practice Address - Zip Code:08403-1436
Practice Address - Country:US
Practice Address - Phone:609-335-8275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD1211213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2263009Medicaid
NJMD1211OtherSTATE MED LIC
NJT2765Medicare UPIN
IE575928Medicare ID - Type Unspecified