Carmine John Petracca, OD

Primary specialty

OptometristTaxonomy code 152W00000X

License

ODP634 Issued in ID

Practice address

939 Bryden
Lewiston, ID 83501-5097

Phone

(208) 743-1761

Fax

(208) 746-8042

NPI assigned

Aug 24, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156377600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1457468613",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "939 BRYDEN",
            "city": "LEWISTON",
            "state": "ID",
            "postal_code": "835015097",
            "telephone_number": "208-743-1761",
            "fax_number": "208-746-8042"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "939 BRYDEN",
            "city": "LEWISTON",
            "state": "ID",
            "postal_code": "835015097",
            "telephone_number": "208-743-1761",
            "fax_number": "208-746-8042"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETRACCA",
        "first_name": "CARMINE",
        "middle_name": "JOHN",
        "name_prefix": "Dr.",
        "credential": "OD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-08-24",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "ID",
            "license": "ODP634",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Perio Docs - Lewiston PLLC
• David A Petersen, MD
• Alan Clifton Peterson, M.D.
• Lisa Peterson, PHARMD
• Mark W Peterson, M.D.
• Raynette Pearl Petrie, LCSW
• Brooke Peidan Pfaff
• Phil Waggoner
• Phillips Agency, Inc
• James R Phillips, PH.D.

• Optometrist in Lewiston, ID
• Providers in Lewiston, ID by specialty
• Optometrist in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.