Provider Demographics
NPI:1720150683
Name:PEZZUTI, ROGER T (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:T
Last Name:PEZZUTI
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 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0078952085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30007026Medicaid
ME305170099Medicaid
ME5023092OtherAETNA
ME1040947OtherAETNA USHC
MEM52973OtherCIGNA
MEB86369OtherHPHC
NH01Y000185NH01OtherANTHEM
ME026375OtherANTHEM
NHRE7127Medicare ID - Type Unspecified
ME305170099Medicaid
NH30007026Medicaid
ME1040947OtherAETNA USHC