Healthcare Provider Details

I. General information

NPI: 1164553285
Provider Name (Legal Business Name): JOSEPH L. PETRUSEK, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 SUNSET DR STE. D
LA GRANDE OR
97850-1200
US

IV. Provider business mailing address

710 SUNSET DR STE. D
LA GRANDE OR
97850-1200
US

V. Phone/Fax

Practice location:
  • Phone: 541-963-8643
  • Fax: 541-963-5845
Mailing address:
  • Phone: 541-963-8643
  • Fax: 541-963-5845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD09444
License Number StateOR

VIII. Authorized Official

Name: DR. JOSEPH LOUIS PETRUSEK
Title or Position: OWNER
Credential: M.D.
Phone: 541-963-8643