Provider Demographics
NPI:1124201819
Name:PETELIN, PAUL M SR (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:PETELIN
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14275 N 87TH ST
Mailing Address - Street 2:STE 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:
Practice Address - Street 1:14275 N 87TH ST
Practice Address - Street 2:STE 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?:Yes
Enumeration Date:2007-12-17
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5845207NS0135X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD00109Medicare UPIN