Provider Demographics
NPI:1225075385
Name:PETRELLI, RICHARD L (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:PETRELLI
Suffix:
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 1:3018 DIXWELL AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3508
Mailing Address - Country:US
Mailing Address - Phone:203-281-5800
Mailing Address - Fax:
Practice Address - Street 1:3018 DIXWELL AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3508
Practice Address - Country:US
Practice Address - Phone:203-281-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT018775207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001187756Medicaid
CT180000217Medicare ID - Type Unspecified
CT001187756Medicaid