Provider Demographics
NPI:1831148717
Name:PETRILLA, ELLEN M (OD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:M
Last Name:PETRILLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 17TH STREET, SUITE A110
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80265
Mailing Address - Country:US
Mailing Address - Phone:303-298-9410
Mailing Address - Fax:
Practice Address - Street 1:1050 17TH STREET, SUITE A110
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80265
Practice Address - Country:US
Practice Address - Phone:303-298-9410
Practice Address - Fax:303-298-8648
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2312152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MP1392846OtherDEA
CO810311Medicare PIN
MP1392846OtherDEA