Healthcare Provider Details

I. General information

NPI: 1699772988
Provider Name (Legal Business Name): ROBERT K PETRELLI O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NEW JERSEY AVE
NORTH WILDWOOD NJ
08260-2738
US

IV. Provider business mailing address

1400 NEW JERSEY AVE
NORTH WILDWOOD NJ
08260-2738
US

V. Phone/Fax

Practice location:
  • Phone: 609-522-4199
  • Fax: 609-522-3692
Mailing address:
  • Phone: 609-522-4199
  • Fax: 609-522-3692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberNJ3013
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberPA-OE004707L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: