Provider Demographics
NPI:1255336079
Name:INNOCENZI, ANTHONY (DPM)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:INNOCENZI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6715 TIPPECANOE RD
Mailing Address - Street 2:BUILDING F UNIT 101
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-8180
Mailing Address - Country:US
Mailing Address - Phone:330-702-0978
Mailing Address - Fax:
Practice Address - Street 1:6715 TIPPECANOE RD
Practice Address - Street 2:BUILDING F UNIT 101
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-8180
Practice Address - Country:US
Practice Address - Phone:330-702-0978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-3012-I213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018292210001Medicaid
OH2046191Medicaid
OH3928630001Medicare NSC
PA0018292210001Medicaid
OH2046191Medicaid