Provider Demographics
NPI:1184625337
Name:PETROZZO, PAUL J (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:PETROZZO
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 1:116 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-9415
Mailing Address - Country:US
Mailing Address - Phone:276-935-8268
Mailing Address - Fax:
Practice Address - Street 1:RR 5 BOX 20
Practice Address - Street 2:STATE ROUTE 83
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-9611
Practice Address - Country:US
Practice Address - Phone:276-523-7938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012371742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010129231Medicaid
C09440Medicare ID - Type Unspecified
A63786Medicare UPIN