Provider Demographics
NPI:1811988165
Name:PETROCELLI, MICHAEL JOHN (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:PETROCELLI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 HERITAGE TRL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34112-8715
Mailing Address - Country:US
Mailing Address - Phone:239-775-0019
Mailing Address - Fax:239-775-0219
Practice Address - Street 1:1715 HERITAGE TRL
Practice Address - Street 2:SUITE 204
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34112-8715
Practice Address - Country:US
Practice Address - Phone:239-775-0019
Practice Address - Fax:239-775-0219
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO-2399213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340308400Medicaid
FL4544600001OtherDMERC #
FL4574474OtherAETNA #
FL65356OtherBLUE CROSS BLUE SHIELD
FL4544600001OtherDMERC #
FLU51713Medicare UPIN
FL65356AMedicare ID - Type UnspecifiedMEDICARE #