Provider Demographics
NPI:1164494720
Name:BOZZUTO, THOMAS M (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:BOZZUTO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:300 LACKAWANNA AVE STE 150
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-2001
Practice Address - Country:US
Practice Address - Phone:570-703-7493
Practice Address - Fax:570-703-7119
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA056978207PE0005X
PAOS004664L207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000690533YMedicaid
GA000690533YMedicaid