Provider Demographics
NPI:1780684084
Name:PETOLILLO, JOHN JR (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PETOLILLO
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MIDDLETOWN BLVD
Mailing Address - Street 2:SUITE 101D
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-1832
Mailing Address - Country:US
Mailing Address - Phone:215-750-6700
Mailing Address - Fax:215-750-6700
Practice Address - Street 1:240 MIDDLETOWN BLVD
Practice Address - Street 2:SUITE 101D
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-1832
Practice Address - Country:US
Practice Address - Phone:215-750-6700
Practice Address - Fax:215-750-6700
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008198L207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA200044351OtherTRAVELERS MEDICARE
PA200044351OtherTRAVELERS MEDICARE
F67903Medicare UPIN
PA3938180001Medicare NSC