Provider Demographics
NPI:1457468613
Name:PETRACCA, CARMINE JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:CARMINE
Middle Name:JOHN
Last Name:PETRACCA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 BRYDEN
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5097
Mailing Address - Country:US
Mailing Address - Phone:208-743-1761
Mailing Address - Fax:208-746-8042
Practice Address - Street 1:939 BRYDEN
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5097
Practice Address - Country:US
Practice Address - Phone:208-743-1761
Practice Address - Fax:208-746-8042
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP634152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1591251Medicare ID - Type Unspecified
T44335Medicare UPIN