Provider Demographics
NPI:1891713228
Name:PETRUS, EARL PAUL (MD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:PAUL
Last Name:PETRUS
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:PO BOX 64487
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064
Mailing Address - Country:US
Mailing Address - Phone:310-820-7197
Mailing Address - Fax:310-478-1876
Practice Address - Street 1:21000 PLUMMER ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-4903
Practice Address - Country:US
Practice Address - Phone:818-882-6400
Practice Address - Fax:818-882-6404
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA197502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A197500Medicaid
CA00A197500Medicaid
A82109Medicare UPIN