Provider Demographics
NPI:1578615936
Name:PETRUZZO, ROBERT T JR (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:PETRUZZO
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 PINE DR
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-7248
Mailing Address - Country:US
Mailing Address - Phone:000-000-0000
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:4405 VANDEVER AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3315
Practice Address - Country:US
Practice Address - Phone:619-528-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A42552085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX42550Medicaid
CA00AX42550Medicaid