Provider Demographics
NPI:1083728448
Name:PETRISKO, JOHN H (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:PETRISKO
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 1:1215 DUFF AVE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-5469
Mailing Address - Country:US
Mailing Address - Phone:515-239-4400
Mailing Address - Fax:
Practice Address - Street 1:1215 DUFF AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-5469
Practice Address - Country:US
Practice Address - Phone:515-239-4496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-535552083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000094776OtherBCBS PIN
MT0157046OtherMDCD PIN
MT000094776OtherBCBS PIN
MT011000111Medicare PIN