Provider Demographics
NPI:1619312295
Name:DEPETRIS, ROBERTO NESTOR (LAC)
Entity Type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:NESTOR
Last Name:DEPETRIS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9501 ACCORD DR
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-4302
Mailing Address - Country:US
Mailing Address - Phone:301-520-7017
Mailing Address - Fax:
Practice Address - Street 1:14300 GALLANT FOX LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4003
Practice Address - Country:US
Practice Address - Phone:301-520-7017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01746171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist