Provider Demographics
NPI:1578932406
Name:IMPELLIZZERI, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:IMPELLIZZERI
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 1:4639 JUTLAND DR
Mailing Address - Street 2:
Mailing Address - City:JAMESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13078-9507
Mailing Address - Country:US
Mailing Address - Phone:315-469-6670
Mailing Address - Fax:
Practice Address - Street 1:421 MONTGOMERY ST
Practice Address - Street 2:ROOM 80 BASEMENT
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2923
Practice Address - Country:US
Practice Address - Phone:315-435-3236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339787363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily