Provider Demographics
NPI:1043506637
Name:PETRUCELLI, MARISA PARISE (DO)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:PARISE
Last Name:PETRUCELLI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11781 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:SUITE 550
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3309
Mailing Address - Country:US
Mailing Address - Phone:571-777-5106
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:175 HIGH ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-1004
Practice Address - Country:US
Practice Address - Phone:973-383-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT014334207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0412830Medicaid