Provider Demographics
NPI:1538108832
Name:RENZULLI, JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:RENZULLI
Suffix:
Gender:M
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:PO BOX 208058
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8058
Mailing Address - Country:US
Mailing Address - Phone:203-737-7652
Mailing Address - Fax:203-785-4043
Practice Address - Street 1:195 COLLYER ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-1869
Practice Address - Country:US
Practice Address - Phone:401-272-7799
Practice Address - Fax:401-272-9299
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT60085208800000X
RIMD11757208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9004842Medicaid
RI33583OtherBLUE SHIELD
RI349005986OtherMEDICARE GROUP PTAN
RI1659463230OtherGROUP NPI
RI349005986OtherMEDICARE GROUP PTAN
RI33583OtherBLUE SHIELD