Provider Demographics
NPI:1225540222
Name:PETIX, GERARD JOSEPH (PT)
Entity Type:Individual
Prefix:MR
First Name:GERARD
Middle Name:JOSEPH
Last Name:PETIX
Suffix:
Gender:M
Credentials:PT
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 20280
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14602-0280
Mailing Address - Country:US
Mailing Address - Phone:585-733-8596
Mailing Address - Fax:
Practice Address - Street 1:1111 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3005
Practice Address - Country:US
Practice Address - Phone:585-241-1612
Practice Address - Fax:585-241-1265
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006646-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006646-1OtherNYS PHYSICAL THERAPY LICENSE #