Provider Demographics
NPI:1255307823
Name:CRETELLA, MICHELLE A (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:CRETELLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ANDERSEN CT
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-3712
Mailing Address - Country:US
Mailing Address - Phone:401-539-2461
Mailing Address - Fax:401-539-2663
Practice Address - Street 1:131 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333-1605
Practice Address - Country:US
Practice Address - Phone:860-739-0348
Practice Address - Fax:860-739-6779
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10078208000000X
CT492312080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIG98868Medicare UPIN