Healthcare Provider Details

I. General information

NPI: 1083896153
Provider Name (Legal Business Name): ROBERT K. PETRELLI, OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 12/04/2007
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 TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberPA-OE004707L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberNJ3013
License Number StateNJ

VIII. Authorized Official

Name: DR. ROBERT K PETRELLI SR.
Title or Position: OWNER
Credential: D.O.
Phone: 609-522-4199