Provider Demographics
NPI:1407876584
Name:PELLEGRINO, JOAN ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:ELIZABETH
Last Name:PELLEGRINO
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 1:725 IRVING AVE
Mailing Address - Street 2:CROUSE POB
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1603
Mailing Address - Country:US
Mailing Address - Phone:315-464-6395
Mailing Address - Fax:315-464-7238
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:CROUSE POB
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-464-6395
Practice Address - Fax:315-464-7238
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233547207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02619152Medicaid
NYRA5198Medicare PIN
NYG62256Medicare UPIN