Provider Demographics
NPI:1598874679
Name:ILLUZZI, ANGELO (DO)
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:
Last Name:ILLUZZI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-503-8573
Mailing Address - Fax:814-503-8574
Practice Address - Street 1:621 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1413
Practice Address - Country:US
Practice Address - Phone:814-503-8573
Practice Address - Fax:814-503-8574
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S008438L207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA740698OtherBLUE SHIELD
PA13489OtherGEISINGER
PA0014671870004Medicaid
PA104291OtherUPMC
P00233037OtherMETRAHEALTH RAILROAD MEDI
610283400OtherBLACK LUNG
PA740698OtherBLUE SHIELD
A64879Medicare UPIN