Provider Demographics
NPI:1699772988
Name:PETRELLI, ROBERT K (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:K
Last Name:PETRELLI
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 1:1400 NEW JERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH WILDWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08260-2738
Mailing Address - Country:US
Mailing Address - Phone:609-522-4199
Mailing Address - Fax:609-522-3692
Practice Address - Street 1:1400 NEW JERSEY AVE
Practice Address - Street 2:
Practice Address - City:NORTH WILDWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08260-2738
Practice Address - Country:US
Practice Address - Phone:609-522-4199
Practice Address - Fax:609-522-3692
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ3013152W00000X
PAPA-OE004707L152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0097739000OtherAMERIHEALTH
NJ455040OtherU.S. HEALTHCARE
NJ2400901Medicaid
NJ0097739000OtherAMERIHEALTH
NJ2400901Medicaid