Provider Demographics
NPI:1235161662
Name:PETRELLIS, LOUIS DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:DANIEL
Last Name:PETRELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 WELSH RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-4241
Mailing Address - Country:US
Mailing Address - Phone:215-673-1444
Mailing Address - Fax:215-673-1704
Practice Address - Street 1:1718 WELSH RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-4241
Practice Address - Country:US
Practice Address - Phone:215-673-1700
Practice Address - Fax:215-673-1704
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S006198L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01272990Medicaid
PA01272990Medicaid
E65394Medicare UPIN