Provider Demographics
NPI:1558477448
Name:PETTINELLI, DAMON JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAMON
Middle Name:JOHN
Last Name:PETTINELLI
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 1:8618 EASTERN MORNING RUN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-5865
Mailing Address - Country:US
Mailing Address - Phone:301-317-4956
Mailing Address - Fax:
Practice Address - Street 1:6231 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-1113
Practice Address - Country:US
Practice Address - Phone:410-377-2044
Practice Address - Fax:410-377-8061
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0058950207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD035N870FMedicare ID - Type Unspecified
MDH66590Medicare UPIN