Provider Demographics
NPI:1770778490
Name:EARL PETRUS MD INC
Entity type:Organization
Organization Name:EARL PETRUS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-820-7197
Mailing Address - Street 1:PO BOX 64487
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-0487
Mailing Address - Country:US
Mailing Address - Phone:310-820-7197
Mailing Address - Fax:310-478-1876
Practice Address - Street 1:21000 PLUMMER ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-4903
Practice Address - Country:US
Practice Address - Phone:818-882-6400
Practice Address - Fax:818-882-6404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A197500Medicaid
CAA19750Medicare PIN