Provider Demographics
NPI:1144514514
Name:PETRIE, MICHAEL JAMES (LDO)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:PETRIE
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44319-3027
Mailing Address - Country:US
Mailing Address - Phone:330-408-9055
Mailing Address - Fax:330-968-0514
Practice Address - Street 1:3308 S MAIN ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44319-3027
Practice Address - Country:US
Practice Address - Phone:330-352-3212
Practice Address - Fax:330-352-3212
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.5057156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician