Provider Demographics
NPI:1063668531
Name:PETELIN, ANTHONY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JOHN
Last Name:PETELIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14275 N 87TH ST
Mailing Address - Street 2:SUITE #110
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-3696
Mailing Address - Country:US
Mailing Address - Phone:480-905-8485
Mailing Address - Fax:480-905-7274
Practice Address - Street 1:14275 N 87TH ST
Practice Address - Street 2:SUITE #110
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-3696
Practice Address - Country:US
Practice Address - Phone:480-905-8485
Practice Address - Fax:480-905-7274
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103734207N00000X
AZ45164207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ9778761OtherAETNA
AZZ163973Medicare PIN