Provider Demographics
NPI:1265819312
Name:PREZZANO, KAVITHA M (MD)
Entity Type:Individual
Prefix:
First Name:KAVITHA
Middle Name:M
Last Name:PREZZANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAVITHA
Other - Middle Name:
Other - Last Name:MANNAVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5008 BRITTONFIELD PKWY STE 700
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9249
Mailing Address - Country:US
Mailing Address - Phone:315-472-7504
Mailing Address - Fax:315-634-4677
Practice Address - Street 1:5008 BRITTONFIELD PKWY STE 700
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9249
Practice Address - Country:US
Practice Address - Phone:315-472-7504
Practice Address - Fax:315-634-4677
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-28
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3027662085R0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY302766OtherNYS LICENSE