Provider Demographics
NPI:1497755441
Name:DEPETRILLO, MICHAEL A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:DEPETRILLO
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1201 NOTT ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-2589
Mailing Address - Country:US
Mailing Address - Phone:518-374-3123
Mailing Address - Fax:518-374-9711
Practice Address - Street 1:1201 NOTT ST
Practice Address - Street 2:SUITE 106
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-2589
Practice Address - Country:US
Practice Address - Phone:518-374-3123
Practice Address - Fax:518-374-9711
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2010-11-10
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Provider Licenses
StateLicense IDTaxonomies
NY127532-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
05104OtherMVP
040426006657OtherFIDELIS
MD000A2810OtherEMPIRE BLUE CROSS
000405064003OtherBLUE SHIELD NENY
127532-1OtherTRICARE NORTH REGION
000405064002OtherBLUE SHIELD NENY
NY00392847Medicaid
00A28OtherEMPIRE BLUE CROSS
110160500OtherUS DEPT OF LABOR
9599341OtherGHI
CAN1275320OtherNO FAULT
10000479OtherCDPHP
CAN1275320OtherWORKERS COMP
MD000A2820OtherEMPIRE BLUE CROSS
000000097790OtherGHI HMO
33570POtherFIDELIS MEDICARE
D01979OtherAMERICAN PROGRESSIVE TODA
MD000A2820OtherEMPIRE BLUE CROSS
D01979OtherAMERICAN PROGRESSIVE TODA
000405064003OtherBLUE SHIELD NENY