Provider Demographics
NPI:1104897552
Name:PETRUZZELLA, VITO (DPM)
Entity type:Individual
Prefix:DR
First Name:VITO
Middle Name:
Last Name:PETRUZZELLA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 SOMERSET ST
Mailing Address - Street 2:
Mailing Address - City:WATCHUNG
Mailing Address - State:NJ
Mailing Address - Zip Code:07069-4941
Mailing Address - Country:US
Mailing Address - Phone:908-834-8810
Mailing Address - Fax:908-834-8814
Practice Address - Street 1:108 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-4659
Practice Address - Country:US
Practice Address - Phone:201-659-5222
Practice Address - Fax:201-659-0847
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD001537213E00000X
NJ25MD00153700213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT45583Medicare UPIN
NJ467620BDQMedicare PIN
NJ467620BDQMedicare PIN