Provider Demographics
NPI:1801953310
Name:PETROULAKIS, EMANUEL
Entity type:Individual
Prefix:
First Name:EMANUEL
Middle Name:
Last Name:PETROULAKIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 HIGH ST N
Mailing Address - Street 2:MONTEFIORE G100
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-3025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:608 HIGH ST N
Practice Address - Street 2:MONTEFIORE G100
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332-3025
Practice Address - Country:US
Practice Address - Phone:856-825-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA68837207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2157126OtherAETNA
NJJ9234OtherHORIZON BCBS
NJP1887344OtherOXFORD
NJG88328Medicare UPIN
NJ024606Medicare ID - Type Unspecified