Provider Demographics
NPI:1215949243
Name:PETOSA, ROBERT J (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:PETOSA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 RALPH PLACE
Mailing Address - Street 2:STE 314
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304
Mailing Address - Country:US
Mailing Address - Phone:718-815-3033
Mailing Address - Fax:718-815-3191
Practice Address - Street 1:11 RALPH PLACE
Practice Address - Street 2:STE 314
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304
Practice Address - Country:US
Practice Address - Phone:718-815-3033
Practice Address - Fax:718-815-3191
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0049821111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
X28661Medicare PIN
T53085Medicare UPIN