Provider Demographics
NPI:1578745386
Name:ANGIULLI, MATTHEW RICHARD
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:RICHARD
Last Name:ANGIULLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CENTRAL PLZ
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-1701
Mailing Address - Country:US
Mailing Address - Phone:315-894-9995
Mailing Address - Fax:
Practice Address - Street 1:4 CENTRAL PLZ
Practice Address - Street 2:
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-1701
Practice Address - Country:US
Practice Address - Phone:315-894-9995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00483569Medicaid