Provider Demographics
NPI:1871765057
Name:PETRUNGARO, JASON MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:MICHAEL
Last Name:PETRUNGARO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:800 MACARTHUR BLVD
Mailing Address - Street 2:SUITE 21
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2917
Mailing Address - Country:US
Mailing Address - Phone:219-836-1163
Mailing Address - Fax:844-270-6677
Practice Address - Street 1:800 MACARTHUR BLVD
Practice Address - Street 2:SUITE 21
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2917
Practice Address - Country:US
Practice Address - Phone:219-836-1163
Practice Address - Fax:844-270-6677
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN99932086S0122X
IN01074460A2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8DT481OtherBLUE CROSS BLUE SHIELD
INMEDICAREOtherIN2244001
INP01602561OtherRR MEDICARE
IN0914915OtherBCBS IN