Provider Demographics
NPI:1417933938
Name:PETRAGLIA, JOHN FRANCIS (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:FRANCIS
Last Name:PETRAGLIA
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 3969
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-3969
Mailing Address - Country:US
Mailing Address - Phone:562-407-2080
Mailing Address - Fax:562-407-2082
Practice Address - Street 1:1601 DOVE ST
Practice Address - Street 2:SUITE 170
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2433
Practice Address - Country:US
Practice Address - Phone:949-474-7246
Practice Address - Fax:949-474-7247
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68169207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G681690Medicaid
CAE63851Medicare UPIN
CAP00757741Medicare PIN
CAWG68169AMedicare PIN
CA00G681690Medicaid