Provider Demographics
NPI:1760470900
Name:KAZZAZ, NELLY YACOUB (MD)
Entity Type:Individual
Prefix:
First Name:NELLY
Middle Name:YACOUB
Last Name:KAZZAZ
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 1:4820 W TAFT RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-2800
Mailing Address - Country:US
Mailing Address - Phone:315-234-0906
Mailing Address - Fax:315-234-4416
Practice Address - Street 1:4820 W TAFT RD
Practice Address - Street 2:SUITE 201
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-2800
Practice Address - Country:US
Practice Address - Phone:315-234-0906
Practice Address - Fax:315-234-4416
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254476207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208409001OtherMEDICARE PTAN
H29417Medicare UPIN