Provider Demographics
NPI:1699861237
Name:PETELIS, MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:PETELIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4198
Mailing Address - Country:US
Mailing Address - Phone:516-280-2599
Mailing Address - Fax:516-280-2597
Practice Address - Street 1:300 OLD COUNTRY RD
Practice Address - Street 2:SUITE 211
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4198
Practice Address - Country:US
Practice Address - Phone:516-280-2599
Practice Address - Fax:516-280-2597
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY211294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY211294OtherLICENSE
NY18V841Medicare ID - Type Unspecified
NY211294OtherLICENSE
NYH17815Medicare UPIN