Provider Demographics
NPI:1346297793
Name:PETRUSEK, JOSEPH LOUIS (MD, PC)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:LOUIS
Last Name:PETRUSEK
Suffix:
Gender:M
Credentials:MD, PC
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 1123
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-6123
Mailing Address - Country:US
Mailing Address - Phone:541-963-8643
Mailing Address - Fax:541-963-5845
Practice Address - Street 1:710 SUNSET DR
Practice Address - Street 2:STE. D
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1200
Practice Address - Country:US
Practice Address - Phone:541-963-8643
Practice Address - Fax:541-963-5845
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09444207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR009100000OtherBLUE CROSS PROVIDER NUMBE
OR041913293OtherRAILROAD MEDICARE NUMBER
OR161026Medicaid
ORC93524Medicare UPIN
ORR0000BHFTZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER