Provider Demographics
NPI:1528001419
Name:PETRELLA, MICHAEL ONOFRIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ONOFRIO
Last Name:PETRELLA
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 1:255 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4812
Mailing Address - Country:US
Mailing Address - Phone:845-368-5048
Mailing Address - Fax:
Practice Address - Street 1:255 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4812
Practice Address - Country:US
Practice Address - Phone:845-368-5048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA074294002080N0001X
NY237170-12080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH77032Medicare UPIN