Provider Demographics
NPI:1699768424
Name:PETRATOS, MARINOS A (MD)
Entity type:Individual
Prefix:
First Name:MARINOS
Middle Name:A
Last Name:PETRATOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-4974
Mailing Address - Country:US
Mailing Address - Phone:212-686-7306
Mailing Address - Fax:212-686-7305
Practice Address - Street 1:317 E 34TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4974
Practice Address - Country:US
Practice Address - Phone:212-686-7306
Practice Address - Fax:212-686-7305
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086502-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY432751Medicare ID - Type UnspecifiedDERMATOLOGY
NYB14561Medicare UPIN