Provider Demographics
NPI:1730264912
Name:PETRIE, JUSTINE ANNE (MD)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:ANNE
Last Name:PETRIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2228 N STATE COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-1361
Mailing Address - Country:US
Mailing Address - Phone:714-990-0700
Mailing Address - Fax:714-990-0142
Practice Address - Street 1:2228 N STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-1361
Practice Address - Country:US
Practice Address - Phone:714-990-0700
Practice Address - Fax:714-990-0142
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC388322084P0800X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine