Provider Demographics
NPI:1740787092
Name:ILLUZZI, GINETTE (DPM)
Entity Type:Individual
Prefix:
First Name:GINETTE
Middle Name:
Last Name:ILLUZZI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 SEWALL AVE APT 7A
Mailing Address - Street 2:
Mailing Address - City:ASBURY PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-6544
Mailing Address - Country:US
Mailing Address - Phone:917-843-1803
Mailing Address - Fax:
Practice Address - Street 1:167 AVENUE AT THE CMN
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4805
Practice Address - Country:US
Practice Address - Phone:732-389-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MD00363100213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program