Provider Demographics
NPI:1871563247
Name:MONGELLUZZO, PHILIP A JR (MD)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:A
Last Name:MONGELLUZZO
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:2247 EAST MAIN STREET
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705
Mailing Address - Country:US
Mailing Address - Phone:203-757-3486
Mailing Address - Fax:203-757-3723
Practice Address - Street 1:2247 EAST MAIN STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705
Practice Address - Country:US
Practice Address - Phone:203-757-3486
Practice Address - Fax:203-757-3723
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2021-06-17
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Provider Licenses
StateLicense IDTaxonomies
CT038887207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001388877Medicaid
CT004245272Medicaid
CTH16811Medicare UPIN
CT004245272Medicaid
CT110008549Medicare PIN