Healthcare Provider Details

I. General information

NPI: 1245331537
Provider Name (Legal Business Name): ANNA ALEKSEEVNA PETROVICH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 COYLE AVE
CARMICHAEL CA
95608-0302
US

IV. Provider business mailing address

3400 DATA DR
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 916-536-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A8324
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: