Individual
DR. JOSEPH LOUIS PETRUSEK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D., P.C.
Contact information
Practice address
710 SUNSET DR, STE. D, LA GRANDE, OR 97850-1200
(541) 963-8643
(541) 963-5845
Mailing address
PO BOX 1123, LA GRANDE, OR 97850-6123
(541) 963-8643
(541) 963-5845
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
Primary
MD09444
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
009100000
BLUE CROSS PROVIDER NUMBE
OR
01
—
041913293
RAILROAD MEDICARE NUMBER
OR
05
—
161026
—
OR
Enumeration date
05/30/2006
Last updated
09/24/2020
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