Healthcare Provider Details

I. General information

NPI: 1194927053
Provider Name (Legal Business Name): AMY W ANZILOTTI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY WAGNER

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 10/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 FOULK ROAD SUITE 101
WILMINGTON DE
19803-3157
US

IV. Provider business mailing address

PO BOX 191
ROCKLAND DE
19723-0191
US

V. Phone/Fax

Practice location:
  • Phone: 302-655-3242
  • Fax: 302-655-5392
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC10007447
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC10007447
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: