Provider Demographics
NPI:1407801004
Name:SANNELLA, MARIA IDA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:IDA
Last Name:SANNELLA
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 1:680 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302
Mailing Address - Country:US
Mailing Address - Phone:508-583-2900
Mailing Address - Fax:508-894-0412
Practice Address - Street 1:680 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302
Practice Address - Country:US
Practice Address - Phone:508-583-2900
Practice Address - Fax:508-894-0412
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225318208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1200283Medicaid
MA1200283Medicaid
I48394Medicare UPIN