Provider Demographics
NPI:1578591814
Name:AVEZZANO, ERIC S (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:S
Last Name:AVEZZANO
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 1:466 OLD HOOK RD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1396
Mailing Address - Country:US
Mailing Address - Phone:201-967-8221
Mailing Address - Fax:
Practice Address - Street 1:466 OLD HOOK RD
Practice Address - Street 2:SUITE #1
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1396
Practice Address - Country:US
Practice Address - Phone:201-967-8221
Practice Address - Fax:201-634-9647
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA54774207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE57339Medicare UPIN