1538136916 NPI number — DR. PERI PETRAS MD

Table of content: DR. PERI PETRAS MD (NPI 1538136916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538136916 NPI number — DR. PERI PETRAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRAS
Provider First Name:
PERI
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538136916
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
170 PROSPECT AVE
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
HACKENSACK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07601-1820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-488-2288
Provider Business Mailing Address Fax Number:
201-488-2298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 PROSPECT AVE
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
HACKENSACK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07601-1820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-488-2288
Provider Business Practice Location Address Fax Number:
201-488-2298
Provider Enumeration Date:
03/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  MA43597 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MA43597 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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