Provider Demographics
NPI:1083896153
Name:ROBERT K. PETRELLI, OD
Entity Type:Organization
Organization Name:ROBERT K. PETRELLI, OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:K
Authorized Official - Last Name:PETRELLI
Authorized Official - Suffix:SR
Authorized Official - Credentials:DO
Authorized Official - Phone:609-522-4199
Mailing Address - Street 1:1400 NEW JERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH WILDWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08260-2738
Mailing Address - Country:US
Mailing Address - Phone:609-522-4199
Mailing Address - Fax:609-522-3692
Practice Address - Street 1:1400 NEW JERSEY AVE
Practice Address - Street 2:
Practice Address - City:NORTH WILDWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08260-2738
Practice Address - Country:US
Practice Address - Phone:609-522-4199
Practice Address - Fax:609-522-3692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ3013332BC3200X
PAPA-OE004707L332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0097739000OtherAMERIHEALTH
NJ2400901Medicaid
NJ455040OtherAETNA
NJ0097739000OtherAMERIHEALTH
NJ455040OtherAETNA
NJ2400901Medicaid