Provider Demographics
NPI:1457310724
Name:PELLETIER, MARIO EMILIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:EMILIO
Last Name:PELLETIER
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 1:6003 MONROE PL
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-5440
Mailing Address - Country:US
Mailing Address - Phone:201-869-6868
Mailing Address - Fax:
Practice Address - Street 1:6003 MONROE PL
Practice Address - Street 2:SUITE 1A
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-5463
Practice Address - Country:US
Practice Address - Phone:201-869-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ42560207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ42D671OtherEMPIRE BLUE CROSS
NJ2324105Medicaid
NJ2324105Medicaid
NJD06633Medicare UPIN