Provider Demographics
NPI:1871517102
Name:PETRULLI, PUTT C (DPM)
Entity type:Individual
Prefix:
First Name:PUTT
Middle Name:C
Last Name:PETRULLI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N GARFIELD AVE
Mailing Address - Street 2:#6
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-2400
Mailing Address - Country:US
Mailing Address - Phone:626-282-9950
Mailing Address - Fax:
Practice Address - Street 1:330 N GARFIELD AVE
Practice Address - Street 2:#6
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-2400
Practice Address - Country:US
Practice Address - Phone:626-282-9950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2492213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E24920Medicaid
T11356Medicare UPIN
CA000E24920Medicaid