Provider Demographics
NPI:1790885044
Name:PETROSINO, DAVID MARC X (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MARC
Last Name:PETROSINO
Suffix:X
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HAMILTON AVE # 1
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-4819
Mailing Address - Country:US
Mailing Address - Phone:315-252-2828
Mailing Address - Fax:315-255-1965
Practice Address - Street 1:5 HAMILTON AVE # 1
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-4819
Practice Address - Country:US
Practice Address - Phone:315-252-2828
Practice Address - Fax:315-255-1965
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006097111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCO-6097-2OtherNYS WORKER'S COMPENSATIO
NY006097OtherLISCENCE NUMBER
NY816181OtherMPN EMPIRE PLAN
NYU13228Medicare UPIN
NY006097OtherLISCENCE NUMBER
NY52607BMedicare ID - Type Unspecified