Provider Demographics
NPI:1508806480
Name:PELLETIER, JAMES P (DPM)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:P
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:21017 NYS RTE 12F
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4999
Mailing Address - Country:US
Mailing Address - Phone:315-785-3668
Mailing Address - Fax:315-779-2090
Practice Address - Street 1:18564 US ROUTE 11
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-785-3668
Practice Address - Fax:315-779-2090
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-12-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NYN0046841213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01561357Medicaid
NY01561357Medicaid
0840250001Medicare NSC
NYAA0664Medicare PIN