Provider Demographics
NPI:1174557367
Name:PEZZULLO, DAVID J (PT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:PEZZULLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 DUDLEY ST
Mailing Address - Street 2:STE 200
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-3236
Mailing Address - Country:US
Mailing Address - Phone:401-330-1428
Mailing Address - Fax:
Practice Address - Street 1:1 KETTLE POINT AVE
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-5375
Practice Address - Country:US
Practice Address - Phone:401-884-1177
Practice Address - Fax:401-884-8697
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI26729OtherBLUE CROSS BLUE SHIELD