=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558477448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAMON JOHN PETTINELLI M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6231 N CHARLES ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21212-1113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-377-2044
-----------------------------------------------------
Fax | 410-377-8061
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8618 EASTERN MORNING RUN
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20723-5865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-317-4956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | D0058950
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------