Provider Demographics
NPI:1316260714
Name:VIZZO, VINCENT (PA)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:VIZZO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 E MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2916
Mailing Address - Country:US
Mailing Address - Phone:631-361-5302
Mailing Address - Fax:631-361-8607
Practice Address - Street 1:290 E MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2916
Practice Address - Country:US
Practice Address - Phone:631-361-5302
Practice Address - Fax:631-361-8607
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013939363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWZWYR1Medicare PIN
CTC03778Medicare PIN