Provider Demographics
NPI:1487997581
Name:GERALD MICALIZZI, M.D., LLC
Entity type:Organization
Organization Name:GERALD MICALIZZI, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MICALIZZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-260-2493
Mailing Address - Street 1:558 FAIRVIEW AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606
Mailing Address - Country:US
Mailing Address - Phone:203-260-2493
Mailing Address - Fax:
Practice Address - Street 1:558 FAIRVIEW AVENUE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606
Practice Address - Country:US
Practice Address - Phone:203-374-0793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225913-12085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty