Provider Demographics
NPI:1366908683
Name:PETROVICH, BRANDON MICHAEL (RD, LD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:MICHAEL
Last Name:PETROVICH
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6543 CLIFTON PARK CIR N APT 202
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-1168
Mailing Address - Country:US
Mailing Address - Phone:740-975-8104
Mailing Address - Fax:
Practice Address - Street 1:1699 W MOUND ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-1855
Practice Address - Country:US
Practice Address - Phone:614-278-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH86068476133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered