Provider Demographics
NPI:1194927053
Name:ANZILOTTI, AMY W (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:W
Last Name:ANZILOTTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19723-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:910 FOULK ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3157
Practice Address - Country:US
Practice Address - Phone:302-655-3242
Practice Address - Fax:302-655-5392
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10007447208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0136247Medicaid
PA102040993Medicaid
MD413092800Medicaid
DEI24507Medicare UPIN
491927Medicare ID - Type Unspecified
MD413092800Medicaid