Provider Demographics
NPI:1295953073
Name:PETRO, JAMES MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MICHAEL
Last Name:PETRO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 FAIRCOURT DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7802
Mailing Address - Country:US
Mailing Address - Phone:813-262-2623
Mailing Address - Fax:
Practice Address - Street 1:2140 EAST BLOOMINGDALE AVE
Practice Address - Street 2:WALMART VISION CENTER
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596
Practice Address - Country:US
Practice Address - Phone:813-413-3323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3266152WC0802X, 152WP0200X, 152WS0006X, 152WX0102X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
11221055OtherCAQH PROVIDER
FLU78759Medicare UPIN