Provider Demographics
NPI:1770704454
Name:PETRUCCO, LOUIS ALFRED (MD)
Entity type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:ALFRED
Last Name:PETRUCCO
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 1:9966 HAWTHORN GLEN
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-2100
Mailing Address - Country:US
Mailing Address - Phone:734-552-1561
Mailing Address - Fax:
Practice Address - Street 1:9966 HAWTHORNE GLEN DR
Practice Address - Street 2:
Practice Address - City:GROSSE ILE
Practice Address - State:MI
Practice Address - Zip Code:48138-2100
Practice Address - Country:US
Practice Address - Phone:734-552-1561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315026105207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology