Provider Demographics
NPI:1386136380
Name:PETRO, SAMUEL (OD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
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 1:2506 BORDEAUX WAY
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559
Mailing Address - Country:US
Mailing Address - Phone:317-418-6170
Mailing Address - Fax:
Practice Address - Street 1:900 N BELCHER RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-2105
Practice Address - Country:US
Practice Address - Phone:317-418-6170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5529152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist