Provider Demographics
NPI:1598751083
Name:PIETRUCHA, DOROTHY MARY (MD)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:MARY
Last Name:PIETRUCHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 DAVIS AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-4483
Mailing Address - Country:US
Mailing Address - Phone:732-776-4551
Mailing Address - Fax:732-776-4392
Practice Address - Street 1:81 DAVIS AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4483
Practice Address - Country:US
Practice Address - Phone:732-776-4551
Practice Address - Fax:732-776-4392
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA023316002084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C54216Medicare UPIN
NJ151569UWHMedicare PIN
NJ151569UWHMedicare PIN
NJ3055205Medicaid