Healthcare Provider Details

I. General information

NPI: 1043605231
Provider Name (Legal Business Name): JENNY LEE PETRAUSKAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MAIN ST
UNIONVILLE CT
06085-1131
US

IV. Provider business mailing address

67 PUNCH BROOK RD
BURLINGTON CT
06013-1814
US

V. Phone/Fax

Practice location:
  • Phone: 860-673-6124
  • Fax:
Mailing address:
  • Phone: 860-803-2989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number61440
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: