Provider Demographics
NPI:1336231364
Name:DEPETRIS, ROBERTO A (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:A
Last Name:DEPETRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:14300 GALLANT FOX LANE
Mailing Address - Street 2:122
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715
Mailing Address - Country:US
Mailing Address - Phone:301-464-0770
Mailing Address - Fax:301-464-1155
Practice Address - Street 1:14300 GALLANT FOX LANE
Practice Address - Street 2:122
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715
Practice Address - Country:US
Practice Address - Phone:301-464-0770
Practice Address - Fax:301-464-1155
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD19252207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
410014Medicare ID - Type Unspecified
B94671Medicare UPIN