Provider Demographics
NPI:1013962091
Name:FEDULLO, ANTHONY J (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:J
Last Name:FEDULLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1425 PORTLAND AVE
Mailing Address - Street 2:BOX 242
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3001
Mailing Address - Country:US
Mailing Address - Phone:585-922-4409
Mailing Address - Fax:585-922-4833
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3001
Practice Address - Country:US
Practice Address - Phone:585-922-4409
Practice Address - Fax:585-922-4833
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126101207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00469365Medicaid
NY70005AMedicare PIN
NY11201OMedicare PIN
NYJ400097545Medicare PIN