Provider Demographics
NPI:1306839527
Name:PEDERZOLLI, JOSEPH M (OD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
Last Name:PEDERZOLLI
Suffix:
Gender:M
Credentials:OD
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 2938
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-0938
Mailing Address - Country:US
Mailing Address - Phone:330-913-7333
Mailing Address - Fax:330-913-7334
Practice Address - Street 1:32 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-2647
Practice Address - Country:US
Practice Address - Phone:330-913-7333
Practice Address - Fax:330-913-7334
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3433T596152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000135321OtherANTHEM
OH0399911Medicaid
OH0399911Medicaid
T48485Medicare UPIN
OH0591431Medicare PIN
OH0591431Medicare PIN