Provider Demographics
NPI:1043200140
Name:PETTELLA, MICHAEL J (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:PETTELLA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6175 SE 126TH LN
Mailing Address - Street 2:
Mailing Address - City:BELLEVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:34420-5208
Mailing Address - Country:US
Mailing Address - Phone:352-245-8300
Mailing Address - Fax:
Practice Address - Street 1:6175 S.E. 126TH LANE
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-5208
Practice Address - Country:US
Practice Address - Phone:352-245-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006496111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL350052194OtherRAILROAD MEDICARE
FLU42053Medicare UPIN
FL22882Medicare ID - Type Unspecified