Healthcare Provider Details

I. General information

NPI: 1003905522
Provider Name (Legal Business Name): GEORGE PETZINGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 E MEAD AVE
YAKIMA WA
98903-3720
US

IV. Provider business mailing address

402 N 4TH STREET SUITE 202
YAKIMA WA
98901
US

V. Phone/Fax

Practice location:
  • Phone: 509-453-1344
  • Fax: 509-453-2209
Mailing address:
  • Phone: 509-248-3782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD00038547
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8254252
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 2
Identifier139616
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerL & I
# 3
Identifier911019392
Identifier TypeOTHER
Identifier State
Identifier IssuerCOMMERCIAL
# 4
Identifier8254252
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerCHPW

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: