Provider Demographics
NPI:1568525806
Name:PETRUS, GARY MICHAEL (MD)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:MICHAEL
Last Name:PETRUS
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 241580
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-0011
Mailing Address - Country:US
Mailing Address - Phone:501-614-3052
Mailing Address - Fax:501-614-3057
Practice Address - Street 1:4137 JOHN F KENNEDY BLVD STE A
Practice Address - Street 2:
Practice Address - City:N LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-8230
Practice Address - Country:US
Practice Address - Phone:501-614-3052
Practice Address - Fax:501-614-3057
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC73182082S0099X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR114482001Medicaid