Provider Demographics
NPI:1376668491
Name:PETRUZZELLI, JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:PETRUZZELLI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16A GERRY ST
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-2605
Mailing Address - Country:US
Mailing Address - Phone:781-799-3957
Mailing Address - Fax:
Practice Address - Street 1:491 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-2607
Practice Address - Country:US
Practice Address - Phone:617-627-9099
Practice Address - Fax:617-627-9044
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2405111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor