Provider Demographics
NPI:1619924354
Name:PELLEGRINO, LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:PELLEGRINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 IRVING AVE
Mailing Address - Street 2:CROUSE POB
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1603
Mailing Address - Country:US
Mailing Address - Phone:315-464-6395
Mailing Address - Fax:315-464-7564
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:CROUSE POB
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-464-6395
Practice Address - Fax:315-464-7564
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1858382080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01404291Medicaid
NYF55548Medicare UPIN
NY01404291Medicaid