Provider Demographics
NPI:1881627271
Name:PETRASH, ANTON CYRIL (MD)
Entity type:Individual
Prefix:DR
First Name:ANTON
Middle Name:CYRIL
Last Name:PETRASH
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 1:3841 BRICKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-8226
Mailing Address - Country:US
Mailing Address - Phone:707-569-2367
Mailing Address - Fax:707-569-2444
Practice Address - Street 1:1100 N COLLEGE AVE
Practice Address - Street 2:116A/MHC
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-444-5038
Practice Address - Fax:479-444-5039
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1569472084P0800X
ARE00362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR125759001Medicaid
AR5J418OtherBCBS PROV #
ARF81378Medicare UPIN
AR125759001Medicaid