Provider Demographics
NPI:1457502221
Name:PETRACCA, BRIAN JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JOHN
Last Name:PETRACCA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 N 22ND ST STE 210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4963
Mailing Address - Country:US
Mailing Address - Phone:480-892-8400
Mailing Address - Fax:602-508-4830
Practice Address - Street 1:1515 S 8TH ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-4940
Practice Address - Country:US
Practice Address - Phone:575-544-3937
Practice Address - Fax:575-546-2870
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM592152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM14224283Medicaid