Provider Demographics
NPI:1649268400
Name:MARZULLO, LAURIE RAFAELLE (MD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:RAFAELLE
Last Name:MARZULLO
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 1:1600 7TH AVE S STE 110
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1711
Mailing Address - Country:US
Mailing Address - Phone:205-638-9587
Mailing Address - Fax:205-975-4623
Practice Address - Street 1:1600 7TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1711
Practice Address - Country:US
Practice Address - Phone:205-939-9587
Practice Address - Fax:205-975-4623
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.25381207P00000X, 208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102260Medicaid
AL1649268400OtherTRICARE SOUTH
AL515-173333OtherBCBS
AL5982661OtherAETNA
AL009925235Medicaid
AL515-16808OtherBCBS
AL009925235Medicaid