Provider Demographics
NPI:1417173006
Name:IANNAZZO, ADAM SCOTT (PT)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:SCOTT
Last Name:IANNAZZO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9731 W CANYON TER
Mailing Address - Street 2:#1
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4668
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 N JOHNSON AVE STE G
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-2521
Practice Address - Country:US
Practice Address - Phone:619-444-6113
Practice Address - Fax:619-719-5525
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28858225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist