Provider Demographics
NPI:1568431666
Name:PETRILLO, RAYMOND J (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:J
Last Name:PETRILLO
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 1:4473 PAHEE ST STE L
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-2037
Mailing Address - Country:US
Mailing Address - Phone:808-632-0200
Mailing Address - Fax:808-632-0201
Practice Address - Street 1:4473 PAHEE ST STE L
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-2037
Practice Address - Country:US
Practice Address - Phone:808-632-0200
Practice Address - Fax:808-632-0201
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16666207RN0300X
HIMD-20522207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8129728Medicaid
OR009428Medicaid
ORR00WCGSJFMedicare ID - Type Unspecified
ORD87834Medicare UPIN