Provider Demographics
NPI:1528045481
Name:PETRUZZELLI, GUY J (MD, PHD)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:J
Last Name:PETRUZZELLI
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-2299
Mailing Address - Fax:912-350-2298
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404
Practice Address - Country:US
Practice Address - Phone:912-350-2299
Practice Address - Fax:912-350-2298
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067957207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003124903AMedicaid
GA003124903BMedicaid
GA691344OtherWELLCARE
GAP01069298OtherRAILROAD MEDICARE
GAP01109154OtherRAILROAD MEDICARE
SCGA1328Medicaid
GA003124903BMedicaid
GA202I045446Medicare PIN
GA202I045883Medicare PIN