Provider Demographics
NPI:1518955384
Name:BIZZARO, THOMAS A (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:BIZZARO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9116 158TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-3126
Mailing Address - Country:US
Mailing Address - Phone:718-738-7732
Mailing Address - Fax:718-835-3166
Practice Address - Street 1:9116 158TH AVE
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-3126
Practice Address - Country:US
Practice Address - Phone:718-738-7732
Practice Address - Fax:718-835-3166
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137491207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
53A361OtherBS
NY00597764Medicaid
4338613OtherAETNA
NY00597764Medicaid
4338613OtherAETNA