Provider Demographics
NPI:1538136916
Name:PETRAS, PERI (MD)
Entity type:Individual
Prefix:DR
First Name:PERI
Middle Name:
Last Name:PETRAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 PROSPECT AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1820
Mailing Address - Country:US
Mailing Address - Phone:201-488-2288
Mailing Address - Fax:201-488-2298
Practice Address - Street 1:170 PROSPECT AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1820
Practice Address - Country:US
Practice Address - Phone:201-488-2288
Practice Address - Fax:201-488-2298
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA43597207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMA43597OtherSTATE LICENSE NUMBER
NJC61509Medicare UPIN