Provider Demographics
NPI:1144365941
Name:MARK A. PETROFF, MD PC
Entity type:Organization
Organization Name:MARK A. PETROFF, MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-607-1300
Mailing Address - Street 1:17720 JEAN WAY
Mailing Address - Street 2:#100
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5574
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:#100
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5574
Practice Address - Country:US
Practice Address - Phone:503-635-4886
Practice Address - Fax:503-635-1655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Not Answered2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Multi-Specialty