Provider Demographics
NPI:1043207764
Name:PETRUSKA, MYRON JAY (DO)
Entity Type:Individual
Prefix:DR
First Name:MYRON
Middle Name:JAY
Last Name:PETRUSKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:2240 REMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4725
Mailing Address - Country:US
Mailing Address - Phone:704-671-5311
Mailing Address - Fax:704-671-5308
Practice Address - Street 1:209 PARK ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-5205
Practice Address - Country:US
Practice Address - Phone:704-825-4750
Practice Address - Fax:704-825-6985
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9600678207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00678Medicaid
NC8967080Medicaid
NC2400026Medicare PIN
NC8967080Medicaid