Provider Demographics
NPI:1689709586
Name:PETRUNCIO, GEORGE JOHN (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:JOHN
Last Name:PETRUNCIO
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 1:188 FRIES MILL RD
Mailing Address - Street 2:SUITE E-1
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2015
Mailing Address - Country:US
Mailing Address - Phone:856-875-7700
Mailing Address - Fax:856-262-0428
Practice Address - Street 1:188 FRIES MILL RD
Practice Address - Street 2:SUITE E-1
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-2015
Practice Address - Country:US
Practice Address - Phone:856-875-7700
Practice Address - Fax:856-262-0428
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04931600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E53716Medicare UPIN
610929Medicare ID - Type Unspecified