Provider Demographics
NPI:1558345330
Name:PERAZELLA, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:PERAZELLA
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 1:789 HOWARD AVE
Mailing Address - Street 2:DANA BUILDING - 3RD FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1304
Mailing Address - Country:US
Mailing Address - Phone:203-785-4184
Mailing Address - Fax:203-785-7068
Practice Address - Street 1:789 HOWARD AVE
Practice Address - Street 2:DANA BUILDING - 3RD FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1304
Practice Address - Country:US
Practice Address - Phone:203-785-4184
Practice Address - Fax:203-785-7068
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031004207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001310044Medicaid
CT001310044Medicaid
F51433Medicare UPIN