Provider Demographics
NPI:1669466363
Name:IMPELLIZERI, JOHN (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:IMPELLIZERI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13400 MAIN RD
Mailing Address - Street 2:PO BOX 1619
Mailing Address - City:MATTITUCK
Mailing Address - State:NY
Mailing Address - Zip Code:11952-3209
Mailing Address - Country:US
Mailing Address - Phone:631-298-4479
Mailing Address - Fax:631-298-4236
Practice Address - Street 1:13400 MAIN RD
Practice Address - Street 2:
Practice Address - City:MATTITUCK
Practice Address - State:NY
Practice Address - Zip Code:11952-3209
Practice Address - Country:US
Practice Address - Phone:631-298-4008
Practice Address - Fax:631-298-5969
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224524207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02444824Medicaid
H73703Medicare UPIN
55S201Medicare ID - Type Unspecified