Provider Demographics
NPI:1528056496
Name:PEZZULLO, JOHN ALBERT III (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ALBERT
Last Name:PEZZULLO
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:125 METRO CENTER BLVD STE 2000
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1785
Mailing Address - Country:US
Mailing Address - Phone:401-432-2520
Mailing Address - Fax:401-453-8220
Practice Address - Street 1:125 METRO CENTER BLVD STE 2000
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1785
Practice Address - Country:US
Practice Address - Phone:401-432-2520
Practice Address - Fax:401-453-8220
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2125052085R0202X
RI102442085R0202X
RIMD102442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
007008119OtherMEDICARE
300108647OtherRAILROADMEDICARE
9102814OtherPHHCS
007008121OtherHOSPITAL PIN
1600094OtherUNITEDHEALTHPLANS
0000000001988OtherNHPRI
7008119OtherRIMEDICALASSISTANCE
720099401OtherCIGNA
010244OtherTUFTS
003117117OtherCT MED ASSISTANCE
3208486OtherMASSMEDICAID
010244OtherBLUESHIELD
241272OtherRIHPILGRIM
3208486OtherHEALTHYSTART
407649OtherBLUECHIP
720099401OtherCIGNA