Provider Demographics
NPI:1710023767
Name:PEZZAROSSI, ANGELO GUILLERMO (MD)
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:GUILLERMO
Last Name:PEZZAROSSI
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:PO BOX 16068
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87191-6068
Mailing Address - Country:US
Mailing Address - Phone:505-792-4465
Mailing Address - Fax:505-792-8578
Practice Address - Street 1:1100 ALAMEDA BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114
Practice Address - Country:US
Practice Address - Phone:505-792-4465
Practice Address - Fax:505-792-8578
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM75812084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM13870Medicaid
NM13870Medicaid