Provider Demographics
NPI:1083691794
Name:PETRUFF, CAROL (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:PETRUFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 JORDAN LN
Mailing Address - Street 2:PRIME HEALTHCARE
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1278
Mailing Address - Country:US
Mailing Address - Phone:860-263-0253
Mailing Address - Fax:860-263-0262
Practice Address - Street 1:44 DALE RD
Practice Address - Street 2:PRIME HEALTHCARE
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3612
Practice Address - Country:US
Practice Address - Phone:860-674-8830
Practice Address - Fax:860-674-8984
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033353207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010033353CT01OtherBCBS
CT033353OtherMEDICAL LICENSE
CT001333533Medicaid
CTBP4056962OtherDEA
CT001333533Medicaid
CT033353OtherMEDICAL LICENSE