Provider Demographics
NPI:1164401022
Name:ILLUZZI, JESSICA LEE (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:ILLUZZI
Suffix:
Gender:F
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 9805
Mailing Address - Street 2:300 GEORGE STREET 6TH FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:789 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1304
Practice Address - Country:US
Practice Address - Phone:203-688-4101
Practice Address - Fax:203-688-7274
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040471207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001404714Medicaid
CT001404714Medicaid
CT160002217Medicare ID - Type Unspecified