Provider Demographics
NPI:1972678498
Name:PETUSEVSKY, HOWARD BRUCE (DPM)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:BRUCE
Last Name:PETUSEVSKY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7769 NW 44TH ST
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6203
Mailing Address - Country:US
Mailing Address - Phone:954-742-4343
Mailing Address - Fax:954-572-8335
Practice Address - Street 1:7769 NW 44TH ST
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6203
Practice Address - Country:US
Practice Address - Phone:954-742-4343
Practice Address - Fax:954-572-8335
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1813213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL87950OtherPODIATRY
FL87950OtherPODIATRY
FLK2156Medicare ID - Type UnspecifiedPODIATRY
FL1325450001Medicare NSC
FLU00868Medicare UPIN