Provider Demographics
NPI:1629058201
Name:PETRELLI, NICHOLAS J (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:PETRELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 30170
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-7170
Mailing Address - Country:US
Mailing Address - Phone:302-623-7362
Mailing Address - Fax:302-623-7374
Practice Address - Street 1:4701 OGLETOWN STANTON RD
Practice Address - Street 2:SUITE 1213
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2055
Practice Address - Country:US
Practice Address - Phone:302-623-4550
Practice Address - Fax:302-623-4554
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-00064432086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE009220C35Medicare PIN
DEE97153Medicare UPIN