Provider Demographics
NPI:1487636874
Name:PETRACCA, ANTHONY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:PETRACCA
Suffix:JR
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 1:3 IRONGATE CENTER
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-3471
Mailing Address - Country:US
Mailing Address - Phone:518-793-4409
Mailing Address - Fax:518-793-5886
Practice Address - Street 1:3 IRONGATE CENTER
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3471
Practice Address - Country:US
Practice Address - Phone:518-793-4409
Practice Address - Fax:518-793-5886
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167575207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000401245001OtherBLUE SHIELD NENY
NYCD1981OtherRAILROAD MEDICARE GROUP #
NY10470641OtherCAQH
NY5500215OtherAETNA
NY01346818Medicaid
NY10002650OtherCDPHP
NY56K521OtherBLUE CROSS BLUE SHIELD
NY000000056116OtherGHI-HMO
NY00020592301OtherUNIVERA
NY021200700350OtherFIDELIS
NY08219OtherMVP
NY10002650OtherCDPHP
NYF27827Medicare UPIN