Provider Demographics
NPI:1932129475
Name:PEZZELLA, NICKOLAS L (MD)
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:L
Last Name:PEZZELLA
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 1:2012 MEADE PKWY
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4259
Mailing Address - Country:US
Mailing Address - Phone:757-538-0102
Mailing Address - Fax:757-538-1833
Practice Address - Street 1:2012 MEADE PKWY
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4259
Practice Address - Country:US
Practice Address - Phone:757-538-0102
Practice Address - Fax:757-538-1833
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057162208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00799764OtherRR MEDICARE
VA250011832OtherMEDICARE RR
VA006800688Medicaid
VA006800688Medicaid
VA00Y208M01Medicare PIN
VAH23286Medicare UPIN