Provider Demographics
NPI:1477803849
Name:PETER J. PITOCCHI MD PA
Entity Type:Organization
Organization Name:PETER J. PITOCCHI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PITOCCHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-264-2402
Mailing Address - Street 1:1555 KINGSLEY AVE
Mailing Address - Street 2:STE 501
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4560
Mailing Address - Country:US
Mailing Address - Phone:904-264-2402
Mailing Address - Fax:904-264-0933
Practice Address - Street 1:1555 KINGSLEY AVE
Practice Address - Street 2:STE 501
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4560
Practice Address - Country:US
Practice Address - Phone:904-264-2402
Practice Address - Fax:904-264-0933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062014207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3701689000Medicaid
FL110168454OtherRR MCARE
FLGN133AMedicare PIN
FL3701689000Medicaid