Provider Demographics
NPI:1063549434
Name:PETRINIC, BAMBI (MD)
Entity type:Individual
Prefix:DR
First Name:BAMBI
Middle Name:
Last Name:PETRINIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 NW LAKE WHITNEY PL
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1618
Mailing Address - Country:US
Mailing Address - Phone:772-344-7228
Mailing Address - Fax:772-344-7158
Practice Address - Street 1:513 NW LAKE WHITNEY PL
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1618
Practice Address - Country:US
Practice Address - Phone:772-344-7228
Practice Address - Fax:772-344-7158
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15874OtherBCBS
FLB1645XMedicare PIN
FLBI645ZMedicare PIN