Provider Demographics
NPI:1811085392
Name:ANZALONE, VINCENT P (MD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:P
Last Name:ANZALONE
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 1:79 ASTER STRRET
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-2373
Mailing Address - Country:US
Mailing Address - Phone:519-798-0093
Mailing Address - Fax:
Practice Address - Street 1:847 N BROADWAY
Practice Address - Street 2:SUITE 103
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2373
Practice Address - Country:US
Practice Address - Phone:516-798-0441
Practice Address - Fax:516-797-8044
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157952207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01112165Medicaid
NY87D161Medicare ID - Type UnspecifiedMEDICARE
NY01112165Medicaid