Healthcare Provider Details

I. General information

NPI: 1336112382
Provider Name (Legal Business Name): MICHAEL J PETRUSO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 N TENAYA WAY SUITE 400
LAS VEGAS NV
89128-0424
US

IV. Provider business mailing address

PO BOX 15645 SUITE 150
LAS VEGAS NV
89114-5645
US

V. Phone/Fax

Practice location:
  • Phone: 702-243-8500
  • Fax:
Mailing address:
  • Phone: 702-243-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number6283
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: