Provider Demographics
NPI:1699881284
Name:PETRONIO, ANGELA M (MD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:PETRONIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-2336
Mailing Address - Country:US
Mailing Address - Phone:860-257-4131
Mailing Address - Fax:860-257-4519
Practice Address - Street 1:300 WESTERN BLVD
Practice Address - Street 2:STE A
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4305
Practice Address - Country:US
Practice Address - Phone:860-657-1920
Practice Address - Fax:860-657-1925
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031698207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001316985Medicaid
F10916Medicare UPIN
CT001316985Medicaid