Provider Demographics
NPI:1710045208
Name:PETRUCCELLI, STEPHEN JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JAMES
Last Name:PETRUCCELLI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2902
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963-0401
Mailing Address - Country:US
Mailing Address - Phone:631-725-8209
Mailing Address - Fax:631-725-8209
Practice Address - Street 1:39 DIVISION STREET
Practice Address - Street 2:
Practice Address - City:SAG HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11963
Practice Address - Country:US
Practice Address - Phone:631-725-8209
Practice Address - Fax:631-919-1592
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010203111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU87714Medicare UPIN
NYX4N041Medicare ID - Type UnspecifiedMEDICARE PROVIDE ID