Healthcare Provider Details

I. General information

NPI: 1164596896
Provider Name (Legal Business Name): DANA PETRUS, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18031 HWY 18 SUITE B
APPLE VALLEY CA
92307
US

IV. Provider business mailing address

18031 HWY 18 SUITE B
APPLE VALLEY CA
92307-0000
US

V. Phone/Fax

Practice location:
  • Phone: 760-242-7770
  • Fax: 760-242-7760
Mailing address:
  • Phone: 760-242-7770
  • Fax: 760-242-7760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA79858
License Number StateCA

VIII. Authorized Official

Name: DR. DANA C PETRUS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 760-242-7770