Provider Demographics
NPI:1780684472
Name:PETRUNYAK, MARY L (OD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:PETRUNYAK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHERN CAMBRIA
Mailing Address - State:PA
Mailing Address - Zip Code:15714-1353
Mailing Address - Country:US
Mailing Address - Phone:814-948-8600
Mailing Address - Fax:814-948-8790
Practice Address - Street 1:1008 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:NORTHERN CAMBRIA
Practice Address - State:PA
Practice Address - Zip Code:15714-1353
Practice Address - Country:US
Practice Address - Phone:814-948-8600
Practice Address - Fax:814-948-8790
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG455152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPE959756OtherHIGHMARK
PA0016841060003Medicaid
PA1535716OtherUMWA HEALTH & WELFAREFUND
PA1258900001Medicare NSC
PAU69204Medicare UPIN
PA1535716OtherUMWA HEALTH & WELFAREFUND