Provider Demographics
NPI:1811045164
Name:PETROSINO, PAULA D (DPM)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:D
Last Name:PETROSINO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GULFVIEW CLUB 2204
Mailing Address - Street 2:58 N COLLIER BLVD
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145-3711
Mailing Address - Country:US
Mailing Address - Phone:201-314-2415
Mailing Address - Fax:239-394-5033
Practice Address - Street 1:129 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:HASBROUCK HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07604-1306
Practice Address - Country:US
Practice Address - Phone:201-314-2415
Practice Address - Fax:239-394-5033
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD01407213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1562401Medicaid
NJ1562401Medicaid
T44894Medicare UPIN