Provider Demographics
NPI:1912062647
Name:PETRECCIA AND TROTTER MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PETRECCIA AND TROTTER MEDICAL CORPORATION
Other - Org Name:INFECTIOUS DISEASE CONSULTANTS MED. OFFICE, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:TROTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-996-6500
Mailing Address - Street 1:1275 N. ROSE DRIVE
Mailing Address - Street 2:SUITE 134
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-3919
Mailing Address - Country:US
Mailing Address - Phone:714-996-6500
Mailing Address - Fax:714-996-1722
Practice Address - Street 1:1275 N. ROSE DRIVE
Practice Address - Street 2:SUITE 134
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-3919
Practice Address - Country:US
Practice Address - Phone:714-996-6500
Practice Address - Fax:714-996-1722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65207207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W15729OtherPROVIDER IDENTIFICATION NUMBER
CAGR0048130Medicaid
CA=========OtherTAX ID NUMBER