Provider Demographics
NPI:1487607842
Name:PETRILLO, CLAUDIO R (MD)
Entity type:Individual
Prefix:
First Name:CLAUDIO
Middle Name:R
Last Name:PETRILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3150
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-8150
Mailing Address - Country:US
Mailing Address - Phone:203-523-0100
Mailing Address - Fax:203-523-0480
Practice Address - Street 1:698 WEST AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3302
Practice Address - Country:US
Practice Address - Phone:203-523-0100
Practice Address - Fax:203-523-0480
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT024159208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001241596Medicaid
CT250000222Medicare ID - Type UnspecifiedINDIVIDUAL
CTC08033Medicare UPIN