Provider Demographics
NPI:1275584435
Name:PETUSEVSKY, MITCHELL LEE (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:LEE
Last Name:PETUSEVSKY
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 1:3434 HANCOCK BRIDGE PKWY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7094
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2625
Practice Address - Street 1:700 2ND AVE N
Practice Address - Street 2:SUITE 305
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5756
Practice Address - Country:US
Practice Address - Phone:239-263-8385
Practice Address - Fax:239-263-8592
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLFLME0042752207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064860400Medicaid
FL064860400Medicaid
FLC54579Medicare UPIN