Healthcare Provider Details

I. General information

NPI: 1689689101
Provider Name (Legal Business Name): ANDREW R BUZZELLI O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 SYCAMORE ST
PIKEVILLE KY
41501-9118
US

IV. Provider business mailing address

147 SYCAMORE ST
PIKEVILLE KY
41501-9118
US

V. Phone/Fax

Practice location:
  • Phone: 606-218-5511
  • Fax: 606-218-5509
Mailing address:
  • Phone: 606-218-5511
  • Fax: 606-218-5509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00340800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberKY1973DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: