Provider Demographics
NPI:1245328871
Name:PETELIN, PAUL M JR (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:PETELIN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14269 N 87TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-3695
Mailing Address - Country:US
Mailing Address - Phone:480-483-8882
Mailing Address - Fax:480-736-4836
Practice Address - Street 1:14269 N 87TH ST STE 203
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-3695
Practice Address - Country:US
Practice Address - Phone:480-483-8882
Practice Address - Fax:480-563-1413
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2022-07-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ29999207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH52302Medicare UPIN
AZZ80272Medicare ID - Type UnspecifiedMEDICARE ID