Provider Demographics
NPI:1164596896
Name:DANA PETRUS, M.D., INC.
Entity Type:Organization
Organization Name:DANA PETRUS, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETRUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-242-7770
Mailing Address - Street 1:18031 HWY 18
Mailing Address - Street 2:SUITE B
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-0000
Mailing Address - Country:US
Mailing Address - Phone:760-242-7770
Mailing Address - Fax:760-242-7760
Practice Address - Street 1:18031 HWY 18
Practice Address - Street 2:SUITE B
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-242-7770
Practice Address - Fax:760-242-7760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH92719Medicare UPIN
CAZZZ03895ZMedicare PIN
CADO8827Medicare PIN
CA00A798581Medicare PIN