Provider Demographics
NPI:1245331537
Name:PETROVICH, ANNA ALEKSEEVNA (DO)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:ALEKSEEVNA
Last Name:PETROVICH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6555 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0302
Practice Address - Country:US
Practice Address - Phone:916-536-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8324207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX83240Medicaid
CA1806844OtherGREAT WEST
CA000810608129OtherPHCS
CAMCMG343900OtherWESTERN HEALTH ADVANTAGE
CA106126OtherHEALTH NET
CA2238002OtherFIRST HEALTH
CA236152OtherINTERPLAN
CA7403659OtherAETNA
CA20A8324OtherBLUE CROSS
CA90141470OtherPACIFICARE
CA4441911OtherCIGNA
CA5635513OtherFIRSTH HEALTH
CA20A8324OtherBLUE CROSS
CAMCMG343900OtherWESTERN HEALTH ADVANTAGE