Provider Demographics
NPI:1063446698
Name:PETROFF, JANE VERONICA (MD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:VERONICA
Last Name:PETROFF
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 1:57 NORTH ST STE 216
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5627
Mailing Address - Country:US
Mailing Address - Phone:203-797-9209
Mailing Address - Fax:203-748-7692
Practice Address - Street 1:57 NORTH ST STE 216
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5627
Practice Address - Country:US
Practice Address - Phone:203-797-9209
Practice Address - Fax:203-748-7692
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022321207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001223213Medicaid
CT001223213Medicaid
CT110001006Medicare PIN