Provider Demographics
NPI:1902842990
Name:PETRIE, CLARENCE ROLLAND (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:ROLLAND
Last Name:PETRIE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1837 SUNNYCREST DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3616
Mailing Address - Country:US
Mailing Address - Phone:714-446-6653
Mailing Address - Fax:714-446-6666
Practice Address - Street 1:1837 SUNNYCREST DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3616
Practice Address - Country:US
Practice Address - Phone:714-446-6653
Practice Address - Fax:714-446-6666
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA32946208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA87757Medicare UPIN
CAA32946AMedicare ID - Type Unspecified