Provider Demographics
NPI:1285668350
Name:PETRUZZELLI, ANITA (MD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:PETRUZZELLI
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 1:416 HIGHLAND AVE
Mailing Address - Street 2:BLDG B
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410
Mailing Address - Country:US
Mailing Address - Phone:203-272-1688
Mailing Address - Fax:203-272-2447
Practice Address - Street 1:416 HIGHLAND AVE
Practice Address - Street 2:BLDG B
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410
Practice Address - Country:US
Practice Address - Phone:203-272-1688
Practice Address - Fax:203-272-2447
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034143207VG0400X, 207VX0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00379274Medicare PIN
F93643Medicare UPIN