Provider Demographics
NPI:1447783022
Name:PETRUSO, MATTHEW JAMES (DD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:PETRUSO
Suffix:
Gender:M
Credentials:DD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-5303
Mailing Address - Country:US
Mailing Address - Phone:989-746-7518
Mailing Address - Fax:989-746-7580
Practice Address - Street 1:1000 HOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5303
Practice Address - Country:US
Practice Address - Phone:989-746-7518
Practice Address - Fax:989-746-7580
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02007641A207P00000X
390200000X
MI5101024425207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program