Provider Demographics
NPI:1245205020
Name:PETILON, JULIO (MD)
Entity type:Individual
Prefix:DR
First Name:JULIO
Middle Name:
Last Name:PETILON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 PATRIOT ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6831
Mailing Address - Country:US
Mailing Address - Phone:337-981-2125
Mailing Address - Fax:337-981-2174
Practice Address - Street 1:105 PATRIOT ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6831
Practice Address - Country:US
Practice Address - Phone:337-981-2125
Practice Address - Fax:337-981-2174
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA73625207X00000X, 207X00000X
LA343117207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100128410Medicaid
IN200995080Medicaid