Healthcare Provider Details

I. General information

NPI: 1609985373
Provider Name (Legal Business Name): PHILIP ANTHONY MICALIZZI JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3180 MAIN STREET STE 302
BRIDGEPORT CT
06606
US

IV. Provider business mailing address

3180 MAIN STREET STE 302
BRIDGEPORT CT
06606
US

V. Phone/Fax

Practice location:
  • Phone: 203-372-6505
  • Fax: 203-372-5622
Mailing address:
  • Phone: 203-372-6505
  • Fax: 203-372-5622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number026207
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: