Provider Demographics
NPI:1124134341
Name:MISSANELLI, JOHN S (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:MISSANELLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 HALPERIN AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2631
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:347-479-1303
Practice Address - Street 1:1245 S CEDAR CREST BLVD STE 201
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6258
Practice Address - Country:US
Practice Address - Phone:610-402-4870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321087207V00000X
PAOS003697L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW524Medicare ID - Type Unspecified
CAA93616Medicare UPIN