Provider Demographics
NPI:1285657213
Name:PETRY, CRAIG JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:JOHN
Last Name:PETRY
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 1:102 ARCHWAY CT
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2889
Mailing Address - Country:US
Mailing Address - Phone:434-237-3664
Mailing Address - Fax:434-237-3711
Practice Address - Street 1:102 ARCHWAY CT
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2889
Practice Address - Country:US
Practice Address - Phone:434-237-3664
Practice Address - Fax:434-237-3711
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101059194207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA146316OtherANTHEM BLUE CROSS AND BLU
VA146316OtherANTHEM BLUE CROSS AND BLU
VAG56218Medicare UPIN