Provider Demographics
NPI:1841320561
Name:PETRILLO, PETER MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:MICHAEL
Last Name:PETRILLO
Suffix:
Gender:M
Credentials:DO
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 650859
Mailing Address - Street 2:DEPARTMENT 710
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0859
Mailing Address - Country:US
Mailing Address - Phone:409-772-2222
Mailing Address - Fax:
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:5.504 JENNIE SEALY HOSPITAL
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-0877
Practice Address - Country:US
Practice Address - Phone:409-266-7856
Practice Address - Fax:602-938-4401
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22937363A00000X, 363AS0400X
AZ7881363A00000X
CT001288363AS0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical