Provider Demographics
NPI:1255327532
Name:PETRONELLA, RICHARD M (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:PETRONELLA
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 1:6246 E PIMA ST
Mailing Address - Street 2:#14
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-3156
Mailing Address - Country:US
Mailing Address - Phone:520-296-1719
Mailing Address - Fax:520-296-3889
Practice Address - Street 1:6246 E PIMA ST
Practice Address - Street 2:#14
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-3156
Practice Address - Country:US
Practice Address - Phone:520-296-1719
Practice Address - Fax:520-296-3889
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20559208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
E59766Medicare UPIN
AZMD20559Medicare ID - Type Unspecified