Provider Demographics
NPI:1639209992
Name:PISTILLI, PETER J (CPO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:PISTILLI
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 SCOTTSVILLE RD
Mailing Address - Street 2:SUITE 50
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-5147
Mailing Address - Country:US
Mailing Address - Phone:585-436-7550
Mailing Address - Fax:585-436-4022
Practice Address - Street 1:1280 SCOTTSVILLE RD
Practice Address - Street 2:SUITE 50
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-5147
Practice Address - Country:US
Practice Address - Phone:585-436-7550
Practice Address - Fax:585-436-4022
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCPO00981222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01459943Medicaid
NY01459943Medicaid