Provider Demographics
NPI:1619056405
Name:PITRELLI, JOHN RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:PITRELLI
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 1:398 E DANIA BEACH BLVD
Mailing Address - Street 2:170
Mailing Address - City:DANIA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33004-3051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:398 E DANIA BEACH BLVD
Practice Address - Street 2:170
Practice Address - City:DANIA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33004-3051
Practice Address - Country:US
Practice Address - Phone:954-309-2682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME183712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0652067-00Medicaid
FLD63549Medicare UPIN
FL0652067-00Medicaid