MEDICARE: MICHAEL ALLEN PETRELLI DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	009132	AZ
2	390200000X	Student in an Organized Health Care Education/Training Program
3	2083A0100X	Aerospace Medicine Physician	22738	CA

General Provider Information

NPI Number	:	1184264780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL ALLEN PETRELLI DO

Provider Business Mailing Address
First Line	:	1 DISPENSARY ROAD
Second Line	:
City	:	POINT MUGU NAWC
State	:	CA
Zip	:	93042-5017
Country	:	US
Telephone Number	:	805-989-7213
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 DISPENSARY ROAD
Second Line	:
City	:	POINT MUGU NAWC
State	:	CA
Zip	:	93042-0001
Country	:	US
Telephone Number	:	805-989-8815
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2020
Last Update Date	:	09/10/2024

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