Provider Demographics
NPI:1538239470
Name:PETROCHKO, SERGEI N (OD)
Entity type:Individual
Prefix:DR
First Name:SERGEI
Middle Name:N
Last Name:PETROCHKO
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 1:631 VALLEYVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:ENDWELL
Mailing Address - State:NY
Mailing Address - Zip Code:13760-2550
Mailing Address - Country:US
Mailing Address - Phone:607-786-3741
Mailing Address - Fax:607-786-3741
Practice Address - Street 1:17 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905
Practice Address - Country:US
Practice Address - Phone:607-723-8354
Practice Address - Fax:607-723-9017
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005330152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01482897Medicaid
U36284Medicare UPIN
NY01482897Medicaid