Provider Demographics
NPI:1871286005
Name:PIZZO, ETHAN MICHAEL
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:MICHAEL
Last Name:PIZZO
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:PO BOX 392573
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15251-9573
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:37031 OLD MILL BRIDGE RD UNIT 2
Practice Address - Street 2:
Practice Address - City:SELBYVILLE
Practice Address - State:DE
Practice Address - Zip Code:19975-3940
Practice Address - Country:US
Practice Address - Phone:302-564-7476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-TT10995225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist