Basic Information
| Provider Information | |||||||||
| NPI: | 1669466363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IMPELLIZERI | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13400 MAIN RD | ||||||||
| Address2: | PO BOX 1619 | ||||||||
| City: | MATTITUCK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119523209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312984479 | ||||||||
| FaxNumber: | 6312984236 | ||||||||
| Practice Location | |||||||||
| Address1: | 13400 MAIN RD | ||||||||
| Address2: | |||||||||
| City: | MATTITUCK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119523209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312984008 | ||||||||
| FaxNumber: | 6312985969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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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 | 207R00000X | 224524 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02444824 | 05 | NY | MEDICAID |