MEDICARE: DR. MARK W PETRELLI O.D.

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	152WC0802X	Corneal and Contact Management Optometrist	4625	PA

General Provider Information

NPI Number	:	1427010271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK W PETRELLI O.D.

Provider Business Mailing Address
First Line	:	1400 NEW JERSEY AVE
Second Line	:
City	:	WILDWOOD
State	:	NJ
Zip	:	08260-2738
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 NEW JERSEY AVE
Second Line	:
City	:	WILDWOOD
State	:	NJ
Zip	:	08260-2738
Country	:	US
Telephone Number	:	609-522-4199
Fax Number	:

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

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	07/10/2007

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