Healthcare Provider Details

I. General information

NPI: 1366908683
Provider Name (Legal Business Name): BRANDON MICHAEL PETROVICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

6543 CLIFTON PARK CIR N APT 202
NEW ALBANY OH
43054-1168
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-3000
  • Fax:
Mailing address:
  • Phone: 740-975-8104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: