Provider Demographics
NPI:1609859990
Name:STRAZZULLA, DOMENIC M (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMENIC
Middle Name:M
Last Name:STRAZZULLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:500 CONGRESS ST
Mailing Address - Street 2:SUITE 1A-1
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-0908
Mailing Address - Country:US
Mailing Address - Phone:617-770-1505
Mailing Address - Fax:617-479-6832
Practice Address - Street 1:500 CONGRESS ST
Practice Address - Street 2:SUITE 1A-1
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0908
Practice Address - Country:US
Practice Address - Phone:617-770-1505
Practice Address - Fax:617-479-6832
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA50129207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6191266Medicaid
MAJ04300Medicare ID - Type Unspecified
MA6191266Medicaid