Basic Information
| Provider Information | |||||||||
| NPI: | 1770778490 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EARL PETRUS MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64487 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900640487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108207197 | ||||||||
| FaxNumber: | 3104781876 | ||||||||
| Practice Location | |||||||||
| Address1: | 21000 PLUMMER ST | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913114903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188826400 | ||||||||
| FaxNumber: | 8188826404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 07/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | PETRUS | ||||||||
| AuthorizedOfficialFirstName: | EARL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3108207197 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 00A197500 | 05 | CA | MEDICAID |