Provider Demographics
NPI:1528068129
Name:PETROFF, MARK A (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:PETROFF
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:17720 JEAN WAY
Mailing Address - Street 2:SUITE100
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5394
Mailing Address - Country:US
Mailing Address - Phone:503-635-4886
Mailing Address - Fax:503-635-1655
Practice Address - Street 1:17720 JEAN WAY
Practice Address - Street 2:SUITE100
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5394
Practice Address - Country:US
Practice Address - Phone:503-635-4886
Practice Address - Fax:503-635-1655
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD159962082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD15996OtherSTATE LICENSE
OR069609Medicaid
OR069609Medicaid
ORAP2351459OtherDEA
ORC75694Medicare UPIN