Provider Demographics
NPI:1720278740
Name:PEZZELLO, WILLIAM J JR (DC)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:J
Last Name:PEZZELLO
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 LYCEUM AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3420
Mailing Address - Country:US
Mailing Address - Phone:215-508-5555
Mailing Address - Fax:215-508-5554
Practice Address - Street 1:445 LYCEUM AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-3420
Practice Address - Country:US
Practice Address - Phone:215-508-5555
Practice Address - Fax:215-508-5554
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2014-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008325111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX6V741OtherMEDICARE ID