Healthcare Provider Details

I. General information

NPI: 1003220864
Provider Name (Legal Business Name): ALEXANDER VAZZANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE
ROCHESTER NY
14621-3001
US

IV. Provider business mailing address

245 N 15TH ST
PHILADELPHIA PA
19102-1101
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-4638
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMT206727
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number288929
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: