Provider Demographics
NPI:1316933419
Name:PETRUZZIELLO, FAUSTO (MD)
Entity type:Individual
Prefix:
First Name:FAUSTO
Middle Name:
Last Name:PETRUZZIELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 WASHINGTON AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1724
Mailing Address - Country:US
Mailing Address - Phone:203-672-2800
Mailing Address - Fax:203-672-2801
Practice Address - Street 1:52 WASHINGTON AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-1724
Practice Address - Country:US
Practice Address - Phone:203-672-2800
Practice Address - Fax:203-672-2801
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036943207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2V9255OtherHEALTHNET
CT001369439Medicaid
CTP00441640OtherRAILROADMEDICARE
CT010036943CT01OtherANTHEM BCBS
CT010036943CT07OtherANTHEM BCBS
CT5941638OtherAETNA
CT754451Q040OtherCONNECTICARE
CTP3846616OtherOXFORD HEALTH PLAN
CT754451OtherCONNECTICARE
CT754451OtherCONNECTICARE
CT754451Q040OtherCONNECTICARE
CT5941638OtherAETNA
CT001369439Medicaid