Provider Demographics
NPI:1932738804
Name:PETRALIA, ANTONIO LAWRENCE
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:LAWRENCE
Last Name:PETRALIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1603 WENTZVILLE PKWY
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3826
Practice Address - Country:US
Practice Address - Phone:636-332-8228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025030555207RR0500X
OH57.255235207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology