Provider Demographics
NPI:1225192719
Name:PITTELLI, MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PITTELLI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2727
Mailing Address - Country:US
Mailing Address - Phone:631-264-3937
Mailing Address - Fax:631-598-4496
Practice Address - Street 1:202 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2727
Practice Address - Country:US
Practice Address - Phone:631-264-3937
Practice Address - Fax:631-598-4496
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2024-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6251152W00000X
AZ1337152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZV00173Medicare UPIN
AZ81656Medicare PIN
AZ106214Medicare ID - Type UnspecifiedMEDICARE