Provider Demographics
NPI:1003897935
Name:SCOPELLITO-OLSEN, ANNA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:MARIE
Last Name:SCOPELLITO-OLSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-2918
Mailing Address - Country:US
Mailing Address - Phone:718-668-6963
Mailing Address - Fax:718-351-2147
Practice Address - Street 1:25A JUNE ST STE 111
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-2642
Practice Address - Country:US
Practice Address - Phone:207-490-7998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168980207R00000X, 208000000X
MEMD21516208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY234AV1Medicare PIN
NYE04020Medicare UPIN