Provider Demographics
NPI:1376591917
Name:PETILLO, JAMES JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:JOSEPH
Last Name:PETILLO
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 1:3325 GRIFFIN ROAD
Mailing Address - Street 2:# 257
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-5500
Mailing Address - Country:US
Mailing Address - Phone:954-404-0664
Mailing Address - Fax:954-964-4418
Practice Address - Street 1:3325 GRIFFIN ROAD
Practice Address - Street 2:# 257
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-5500
Practice Address - Country:US
Practice Address - Phone:954-404-0664
Practice Address - Fax:954-964-4418
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2009-08-31
Deactivation Date:2009-02-09
Deactivation Code:
Reactivation Date:2009-08-11
Provider Licenses
StateLicense IDTaxonomies
FLME40178173000000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94046Medicare ID - Type Unspecified
FLD27762Medicare UPIN