Provider Demographics
NPI:1548261944
Name:PETRIK, MARK E (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:PETRIK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:13151 MAGISTERIAL DR
Mailing Address - Street 2:STE 200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4103
Mailing Address - Country:US
Mailing Address - Phone:502-587-1236
Mailing Address - Fax:502-587-0126
Practice Address - Street 1:13151 MAGISTERIAL DR
Practice Address - Street 2:STE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4103
Practice Address - Country:US
Practice Address - Phone:502-587-1236
Practice Address - Fax:502-587-0126
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2010-07-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY26506207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0200907Medicare UPIN
KYE07404Medicare UPIN
KY1269507Medicare PIN