Provider Demographics
NPI:1740272897
Name:PETROLLA, HEATHER ANNETTE (DPM)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANNETTE
Last Name:PETROLLA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 CANFIELD RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-2859
Mailing Address - Country:US
Mailing Address - Phone:330-793-0566
Mailing Address - Fax:330-793-5767
Practice Address - Street 1:924 YOUNGSTOWN POLAND RD
Practice Address - Street 2:
Practice Address - City:STRUTHERS
Practice Address - State:OH
Practice Address - Zip Code:44471-1305
Practice Address - Country:US
Practice Address - Phone:330-707-1360
Practice Address - Fax:330-707-1359
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36 00 1865 P213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
341581408 02OtherOHIO BUREAU OF WORTHERS C
000000134629OtherANTHEM BLUE CROSS BLUE SH
000000134628OtherANTHEM BLUE CROSS BLUE SH
341581408 01OtherOHIO BUREAU OF WORTHERS C
OH0409543Medicaid
000000134627OtherANTHEM BLUE CROSS BLUE SH
27 00411OtherUNITED HEALTHCARE
341581408011OtherMEDICAL MUTUAL
27 00142OtherUNITED HEALTHCARE
341581408009OtherMEDICAL MUTUAL
341581408 02OtherOHIO BUREAU OF WORTHERS C
27 00142OtherUNITED HEALTHCARE
OH0500720003Medicare NSC
OH0500720001Medicare NSC
341581408009OtherMEDICAL MUTUAL
000000134629OtherANTHEM BLUE CROSS BLUE SH
OH0409543Medicaid