Provider Demographics
NPI:1164651113
Name:A. RICHARD PESCITELLI, MD, PA
Entity Type:Organization
Organization Name:A. RICHARD PESCITELLI, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLYATT
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:239-768-6008
Mailing Address - Street 1:33 BARKLEY CIR
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7532
Mailing Address - Country:US
Mailing Address - Phone:239-939-1999
Mailing Address - Fax:239-939-4935
Practice Address - Street 1:33 BARKLEY CIR
Practice Address - Street 2:SUITE A
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7532
Practice Address - Country:US
Practice Address - Phone:239-939-1999
Practice Address - Fax:239-939-4935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL59299174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE61540OtherUPIN
FL59299OtherME
FL052728900Medicaid
FL10D0900367OtherCLIA
FLBP1651644OtherDEA
FL052728900Medicaid