Provider Demographics
NPI:1053392225
Name:PETZ, DARRELL W (DO)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:W
Last Name:PETZ
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 1:1621 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:NATRONA HEIGHTS
Mailing Address - State:PA
Mailing Address - Zip Code:15065-2144
Mailing Address - Country:US
Mailing Address - Phone:724-224-6700
Mailing Address - Fax:724-224-8005
Practice Address - Street 1:1621 UNION AVE
Practice Address - Street 2:
Practice Address - City:NATRONA HEIGHTS
Practice Address - State:PA
Practice Address - Zip Code:15065-2144
Practice Address - Country:US
Practice Address - Phone:724-224-6700
Practice Address - Fax:724-224-8005
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004500L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010307840009Medicaid
PACG1496Medicare PIN
PA0010307840009Medicaid
PA045873R7RMedicare PIN
PAP00164271Medicare PIN