Provider Demographics
NPI:1336116714
Name:PETTORINO, ROSELLE CATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:ROSELLE
Middle Name:CATHERINE
Last Name:PETTORINO
Suffix:
Gender:F
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:PO BOX 5076
Mailing Address - Street 2:864 CENTRAL BLVD STE 300
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78523-5076
Mailing Address - Country:US
Mailing Address - Phone:956-541-6311
Mailing Address - Fax:956-541-6387
Practice Address - Street 1:864 CENTRAL BLVD STE 300
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-7539
Practice Address - Country:US
Practice Address - Phone:956-541-6311
Practice Address - Fax:956-541-6387
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8420174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0048DNOtherBCBS
TX029740001Medicaid
TX0048DNOtherBCBS
TX8F24144OtherPTAN