Provider Demographics
NPI:1750397519
Name:PITOCCHI, PETER JOHN (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:PITOCCHI
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 1:1555 KINGSLEY AVE
Mailing Address - Street 2:SUITE 501
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4560
Mailing Address - Country:US
Mailing Address - Phone:904-264-2402
Mailing Address - Fax:
Practice Address - Street 1:1555 KINGSLEY AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4560
Practice Address - Country:US
Practice Address - Phone:904-264-2402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062014207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370168900Medicaid
FL15016ZMedicare PIN
FL370168900Medicaid