Provider Demographics
NPI:1922068840
Name:IANNUCCI, BRENDA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JEAN
Last Name:IANNUCCI
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 1:1880 RIDGE RD E
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14622-2473
Mailing Address - Country:US
Mailing Address - Phone:585-697-7775
Mailing Address - Fax:585-697-7776
Practice Address - Street 1:1880 RIDGE RD E
Practice Address - Street 2:SUITE 5
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14622-2473
Practice Address - Country:US
Practice Address - Phone:585-697-7775
Practice Address - Fax:585-697-7776
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196460-1207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG27546Medicare UPIN
NYBA0756Medicare ID - Type UnspecifiedMEDICARE