Healthcare Provider Details

I. General information

NPI: 1457502221
Provider Name (Legal Business Name): BRIAN JOHN PETRACCA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 S 8TH ST
DEMING NM
88030-4940
US

IV. Provider business mailing address

4800 N 22ND ST STE 210
PHOENIX AZ
85016-4963
US

V. Phone/Fax

Practice location:
  • Phone: 575-544-3937
  • Fax: 575-546-2870
Mailing address:
  • Phone: 480-892-8400
  • Fax: 602-508-4830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number592
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: