Provider Demographics
NPI:1609960913
Name:IANNUZZI, PHYLLIS LISA (MD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:LISA
Last Name:IANNUZZI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10828 RAVENNA RD
Mailing Address - Street 2:
Mailing Address - City:TWINSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44087-1058
Mailing Address - Country:US
Mailing Address - Phone:330-405-0638
Mailing Address - Fax:330-405-0639
Practice Address - Street 1:10828 RAVENNA RD
Practice Address - Street 2:
Practice Address - City:TWINSBURG
Practice Address - State:OH
Practice Address - Zip Code:44087-1058
Practice Address - Country:US
Practice Address - Phone:330-405-0638
Practice Address - Fax:330-405-0639
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.042760207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0526523Medicaid
OH0526523Medicaid
OH0488683Medicare PIN