Provider Demographics
NPI:1669464624
Name:PETRULIS, PETER JAMES (DO)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JAMES
Last Name:PETRULIS
Suffix:
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:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:STONE RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12484-0547
Mailing Address - Country:US
Mailing Address - Phone:845-687-9933
Mailing Address - Fax:
Practice Address - Street 1:10 GAGNON DR
Practice Address - Street 2:
Practice Address - City:STONE RIDGE
Practice Address - State:NY
Practice Address - Zip Code:12484-5120
Practice Address - Country:US
Practice Address - Phone:845-687-9933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY160527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY087250OtherMVP
NY00950523Medicaid
NY087250OtherMVP
NY70D761Medicare PIN