Provider Demographics
NPI:1184264780
Name:PETRELLI, MICHAEL ALLEN (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLEN
Last Name:PETRELLI
Suffix:
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 1:1 DISPENSARY ROAD
Mailing Address - Street 2:
Mailing Address - City:POINT MUGU NAWC
Mailing Address - State:CA
Mailing Address - Zip Code:93042-5017
Mailing Address - Country:US
Mailing Address - Phone:805-989-7213
Mailing Address - Fax:
Practice Address - Street 1:1 DISPENSARY ROAD
Practice Address - Street 2:
Practice Address - City:POINT MUGU NAWC
Practice Address - State:CA
Practice Address - Zip Code:93042-0001
Practice Address - Country:US
Practice Address - Phone:805-989-8815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ009132208D00000X
390200000X
CA227382083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program