Provider Demographics
NPI:1568583813
Name:FALLONE, ENZO (MD)
Entity Type:Individual
Prefix:
First Name:ENZO
Middle Name:
Last Name:FALLONE
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 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-0553
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTLAND AVENUE
Practice Address - Street 2:PATHOLOGY
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-922-4121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238815207ZP0101X, 207ZP0105X
NY238815-1207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0165492OtherGHI
NY02911475Medicaid
NY7242958OtherAETNA
NYJ400002866Medicare PIN
NYRB4607 (BA0017 GROUPMedicare PIN
NYJ400002865Medicare PIN