Provider Demographics
NPI:1104979590
Name:PETRUSKA, DAVID A (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:PETRUSKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4521 PGA BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-3997
Mailing Address - Country:US
Mailing Address - Phone:561-882-6214
Mailing Address - Fax:561-882-6216
Practice Address - Street 1:927 45TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2450
Practice Address - Country:US
Practice Address - Phone:561-882-6214
Practice Address - Fax:561-882-6216
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2015-04-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY24702174400000X
FLME103531207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0790201Medicare PIN
FLBR447YMedicare PIN
KYF23738Medicare UPIN