Basic Information
| Provider Information | |||||||||
| NPI: | 1154311314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PIZZARELLO | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEPETERS | ||||||||
| OtherFirstName: | MARTHA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 297 PROMENADE ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029085720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014906464 | ||||||||
| FaxNumber: | 6177262894 | ||||||||
| Practice Location | |||||||||
| Address1: | 297 PROMENADE ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029085720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014906464 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD12397 | RI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2045061 | 05 | MA | MEDICAID | 468924 | 01 | MA | TUFTS HEALTH PLAN | OTHER | J27388 | 01 | MA | BCBS MA | OTHER |