Provider Demographics
NPI:1700844024
Name:PETRUNAK, FRED E (OD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:E
Last Name:PETRUNAK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 11TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601
Mailing Address - Country:US
Mailing Address - Phone:814-946-3937
Mailing Address - Fax:814-944-8265
Practice Address - Street 1:1418 11TH AVENUE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601
Practice Address - Country:US
Practice Address - Phone:814-946-3937
Practice Address - Fax:814-946-3937
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000566152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014776200002Medicaid
PA90107ME2Medicare PIN
1213910004Medicare Oscar/Certification
PA0014776200002Medicaid