Provider Demographics
NPI:1952340150
Name:PEZZELLO, PATRICIA (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:PEZZELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 NORTHERN BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5306
Mailing Address - Country:US
Mailing Address - Phone:516-487-8888
Mailing Address - Fax:516-487-8887
Practice Address - Street 1:1010 NORTHERN BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5306
Practice Address - Country:US
Practice Address - Phone:516-487-8888
Practice Address - Fax:516-487-8887
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136277208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB18911Medicare UPIN