Provider Demographics
NPI:1912012410
Name:NIZZA, PHILIP (DO)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:NIZZA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 TECHNOLOGY DR
Mailing Address - Street 2:SUITE 10
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3472
Mailing Address - Country:US
Mailing Address - Phone:631-689-5400
Mailing Address - Fax:631-689-8247
Practice Address - Street 1:14 TECHNOLOGY DR
Practice Address - Street 2:SUITE 10
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3472
Practice Address - Country:US
Practice Address - Phone:631-689-5400
Practice Address - Fax:631-689-8247
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211788207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY211788OtherLICENSE
NY02349264Medicaid
NY211788OtherLICENSE
NY2X0581Medicare ID - Type Unspecified