Provider Demographics
NPI:1811982416
Name:MICALIZZI, GERALD (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:MICALIZZI
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 1:558 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4501
Mailing Address - Country:US
Mailing Address - Phone:203-260-2493
Mailing Address - Fax:
Practice Address - Street 1:558 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4501
Practice Address - Country:US
Practice Address - Phone:203-260-2493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0375282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001375288Medicaid
H49723Medicare UPIN
CT300003190Medicare ID - Type Unspecified