Provider Demographics
NPI:1639252075
Name:PETRUZZI, MARY JANE (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:PETRUZZI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4511 HARLEM RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-3803
Mailing Address - Country:US
Mailing Address - Phone:716-839-6720
Mailing Address - Fax:716-839-6740
Practice Address - Street 1:219 BRYANT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-2006
Practice Address - Country:US
Practice Address - Phone:716-878-7349
Practice Address - Fax:716-888-3801
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1798292080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01169979Medicaid
040426001061OtherFIDELIS
00010137401OtherUNIVERA
1206399OtherIHA
000524343001OtherBC/BS
0015503720001OtherPA MEDICAID
F91604Medicare UPIN
NY01169979Medicaid