Healthcare Provider Details

I. General information

NPI: 1336385350
Provider Name (Legal Business Name): STEVEN RAYMOND PEZZULLO M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2008
Last Update Date: 10/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 TIOGUE AVE
COVENTRY RI
02816-6167
US

IV. Provider business mailing address

982 TIOGUE AVE
COVENTRY RI
02816-6167
US

V. Phone/Fax

Practice location:
  • Phone: 401-821-6800
  • Fax: 401-821-8513
Mailing address:
  • Phone: 401-821-6800
  • Fax: 401-821-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5845
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: