Provider Demographics
NPI:1538160619
Name:PETRANTO, RUSSELL D (DPM)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:D
Last Name:PETRANTO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 BEY LEA RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-2891
Mailing Address - Country:US
Mailing Address - Phone:732-505-9728
Mailing Address - Fax:732-505-9787
Practice Address - Street 1:54 BEY LEA RD
Practice Address - Street 2:SUITE 1
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-2891
Practice Address - Country:US
Practice Address - Phone:732-505-9728
Practice Address - Fax:732-505-9787
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD2031213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4622707Medicaid
NJ469486DNNMedicare ID - Type UnspecifiedPROVIDER IDENTIFICATION #
NJ4622707Medicaid