Provider Demographics
NPI:1639100878
Name:PETKOVIC, MILA (OD)
Entity type:Individual
Prefix:DR
First Name:MILA
Middle Name:
Last Name:PETKOVIC
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 W TALCOTT RD STE 30
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-5559
Practice Address - Country:US
Practice Address - Phone:847-696-2434
Practice Address - Fax:847-696-1481
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46009805152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist