Provider Demographics
NPI:1639245434
Name:PETZOLD, VIRGINIA ANNE (DC)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:ANNE
Last Name:PETZOLD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:VIRGINIA
Other - Middle Name:ANNE
Other - Last Name:TIBALDI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:50 NORTH CHURCH STREET
Mailing Address - Street 2:HOMESTEAD CHIROPRACTIC
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924
Mailing Address - Country:US
Mailing Address - Phone:845-294-1136
Mailing Address - Fax:845-294-1136
Practice Address - Street 1:50 NORTH CHURCH STREET
Practice Address - Street 2:HOMESTEAD CHIROPRACTIC
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924
Practice Address - Country:US
Practice Address - Phone:845-294-1136
Practice Address - Fax:845-294-1136
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006252111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX69561OtherBLUE CROSS BLUE SHIELD
NYP3133088OtherOXFORD HEALTH PLANS
NYX69561Medicare ID - Type Unspecified