MEDICARE: ANDREW JOHN PETULLA P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	PT15558	CA

General Provider Information

NPI Number	:	1063426807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW JOHN PETULLA P.T.

Provider Business Mailing Address
First Line	:	2048 LINCOLN AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-3449
Country	:	US
Telephone Number	:	408-448-1677
Fax Number	:	408-448-7060

Provider Business Practice Location Address
First Line	:	2048 LINCOLN AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-3449
Country	:	US
Telephone Number	:	408-448-1677
Fax Number	:	408-448-7060

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	07/08/2007

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