Healthcare Provider Details

I. General information

NPI: 1184625337
Provider Name (Legal Business Name): PAUL J PETROZZO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 5 BOX 20 STATE ROUTE 83
GRUNDY VA
24614-9611
US

IV. Provider business mailing address

116 FAIRVIEW ST
GRUNDY VA
24614-9415
US

V. Phone/Fax

Practice location:
  • Phone: 276-523-7938
  • Fax:
Mailing address:
  • Phone: 276-935-8268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101237174
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: