Healthcare Provider Details

I. General information

NPI: 1396757209
Provider Name (Legal Business Name): CARMINE BRIAN PETRACCA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 PARK AVE
NEW YORK NY
10028-0959
US

IV. Provider business mailing address

1021 PARK AVE
NEW YORK NY
10028-0959
US

V. Phone/Fax

Practice location:
  • Phone: 212-996-3200
  • Fax:
Mailing address:
  • Phone: 212-996-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number186351
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: