Provider Demographics
NPI:1962437244
Name:PETILLO, TINA M (DO)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:PETILLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 E NORTHFIELD RD STE 2E
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-4892
Mailing Address - Country:US
Mailing Address - Phone:973-533-0001
Mailing Address - Fax:
Practice Address - Street 1:340 EAST NORTHFIELD ROAD
Practice Address - Street 2:SUITE 2E
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-4892
Practice Address - Country:US
Practice Address - Phone:973-533-0001
Practice Address - Fax:973-716-0306
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44503207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7413505Medicaid
NJ699300Medicare ID - Type Unspecified
NJ7413505Medicaid