Provider Demographics
NPI:1376179408
Name:TANZILLO, RICHARD (HIS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:TANZILLO
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4693
Mailing Address - Country:US
Mailing Address - Phone:631-681-0960
Mailing Address - Fax:631-369-2038
Practice Address - Street 1:21 W 2ND ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2752
Practice Address - Country:US
Practice Address - Phone:631-369-2038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000060305237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist