Provider Demographics
NPI:1407872922
Name:PETRELLA, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PETRELLA
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:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48804-0010
Mailing Address - Country:US
Mailing Address - Phone:989-773-2081
Mailing Address - Fax:989-773-3418
Practice Address - Street 1:211 S CRAPO ST
Practice Address - Street 2:SUITE F
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2961
Practice Address - Country:US
Practice Address - Phone:989-773-2081
Practice Address - Fax:989-773-3418
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010404342085N0904X, 2085R0202X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Not Answered2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID91274Medicare UPIN