Provider Demographics
NPI:1811955347
Name:PETRYKOWSKI, MARK JAMES (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:PETRYKOWSKI
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 1:1494 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1825
Mailing Address - Country:US
Mailing Address - Phone:740-344-4747
Mailing Address - Fax:
Practice Address - Street 1:1494 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1825
Practice Address - Country:US
Practice Address - Phone:740-344-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4222152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0934958Medicaid
OHU11472Medicare UPIN
OHPE0752896Medicare PIN