Active NPI
Michael J Petruso, M.D.
- Internal Medicine Physician
- Las Vegas, NV
National Provider Identifier
1336112382
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Internal Medicine Physician
- License
- 6283
- Practice address
- 2704 N Tenaya Way
Suite 400
Las Vegas, NV 89128-0424 - Phone
- (702) 243-8500
- NPI assigned
- Feb 9, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | 6283 | NV | Primary |
Addresses
Primary practice location
2704 N Tenaya Way
Suite 400
Las Vegas, NV 89128-0424
Mailing address
PO Box 15645
Suite 150
Las Vegas, NV 89114-5645
Phone (702) 243-8500
Other identifiers 5
| Identifier | Type | State | Issuer |
|---|---|---|---|
| VWCGZT | Other | NV | MEDICARE GROUP |
| V24262 | Other | NV | LAB |
| 1336112382 | Other | NV | SMA MEDICAID |
| 2019102 | Medicaid | NV | |
| V108716 | Other | NV | SMA MEDICARE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1139443200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1414454400000",
"number": "1336112382",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 15645",
"address_2": "SUITE 150",
"city": "LAS VEGAS",
"state": "NV",
"postal_code": "891145645",
"telephone_number": "702-243-8500"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2704 N TENAYA WAY",
"address_2": "SUITE 400",
"city": "LAS VEGAS",
"state": "NV",
"postal_code": "891280424",
"telephone_number": "702-243-8500"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETRUSO",
"first_name": "MICHAEL",
"middle_name": "J",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-02-09",
"last_updated": "2014-10-28",
"status": "A"
},
"taxonomies": [
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "NV",
"license": "6283",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE GROUP",
"identifier": "VWCGZT",
"state": "NV"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "LAB",
"identifier": "V24262",
"state": "NV"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "SMA MEDICAID",
"identifier": "1336112382",
"state": "NV"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "2019102",
"state": "NV"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "SMA MEDICARE",
"identifier": "V108716",
"state": "NV"
}
],
"endpoints": [],
"other_names": []
}Other providers in Las Vegas, NV
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 28, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.