Provider Demographics
NPI:1346348265
Name:PETZING, CHRISTINE (MD)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:PETZING
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 1:6310 CAPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-5013
Mailing Address - Country:US
Mailing Address - Phone:727-467-7423
Mailing Address - Fax:
Practice Address - Street 1:2675 TAMPA RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3109
Practice Address - Country:US
Practice Address - Phone:727-467-7423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-105731207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113122100Medicaid
ILL92938Medicare ID - Type UnspecifiedINDIVIDUAL #
IL036105731Medicaid
ILCB6569Medicare ID - Type UnspecifiedRR GROUP #
IL080188241Medicare ID - Type UnspecifiedRR INDIVIDUAL #
IL833610Medicare ID - Type UnspecifiedGROUP #