Provider Demographics
NPI:1962708081
Name:BERTOLIZIO, GIANLUCA
Entity type:Individual
Prefix:DR
First Name:GIANLUCA
Middle Name:
Last Name:BERTOLIZIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 TUPPER STREET
Mailing Address - Street 2:ROOM C-1118
Mailing Address - City:MONTREAL
Mailing Address - State:QUEBEC
Mailing Address - Zip Code:H3H 1P3
Mailing Address - Country:CA
Mailing Address - Phone:514-586-2674
Mailing Address - Fax:514-412-4341
Practice Address - Street 1:2300 TUPPER STREET
Practice Address - Street 2:ROOM C-1118
Practice Address - City:MONTREAL
Practice Address - State:QUEBEC
Practice Address - Zip Code:H3H 1P3
Practice Address - Country:CA
Practice Address - Phone:514-586-2674
Practice Address - Fax:514-412-4341
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ07274390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program