Basic Information
| Provider Information | |||||||||
| NPI: | 1528056496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEZZULLO | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ALBERT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 125 METRO CENTER BLVD STE 2000 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028861785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014322520 | ||||||||
| FaxNumber: | 4014538220 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 METRO CENTER BLVD STE 2000 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028861785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014322520 | ||||||||
| FaxNumber: | 4014538220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 212505 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 10244 | RI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD10244 | RI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 007008119 | 01 | MEDICARE | OTHER | 300108647 | 01 | RAILROADMEDICARE | OTHER | 9102814 | 01 | PHHCS | OTHER | 007008121 | 01 | HOSPITAL PIN | OTHER | 1600094 | 01 | UNITEDHEALTHPLANS | OTHER | 0000000001988 | 01 | NHPRI | OTHER | 7008119 | 01 | RIMEDICALASSISTANCE | OTHER | 720099401 | 01 | CIGNA | OTHER | 010244 | 01 | TUFTS | OTHER | 003117117 | 01 | CT MED ASSISTANCE | OTHER | 3208486 | 01 | MASSMEDICAID | OTHER | 010244 | 01 | BLUESHIELD | OTHER | 241272 | 01 | RIHPILGRIM | OTHER | 3208486 | 01 | HEALTHYSTART | OTHER | 407649 | 01 | BLUECHIP | OTHER |