Provider Demographics
NPI:1548499668
Name:PETRARCA, MARK LEWIS (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEWIS
Last Name:PETRARCA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2759
Mailing Address - Country:US
Mailing Address - Phone:401-737-7010
Mailing Address - Fax:401-453-7597
Practice Address - Street 1:455 TOLL GATE RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2759
Practice Address - Country:US
Practice Address - Phone:401-737-7010
Practice Address - Fax:401-453-7597
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP01618390200000X
NH16048207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program