Healthcare Provider Details

I. General information

NPI: 1932389525
Provider Name (Legal Business Name): PAOLO B DEPETRILLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2007
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5204 SANGAMORE RD
BETHESDA MD
20816-2322
US

IV. Provider business mailing address

5204 SANGAMORE RD
BETHESDA MD
20816-2322
US

V. Phone/Fax

Practice location:
  • Phone: 301-320-8648
  • Fax: 301-320-0529
Mailing address:
  • Phone: 301-320-8648
  • Fax: 301-320-0529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number54557
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License Number54557
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: