Provider Demographics
NPI:1083833156
Name:NARIN PETIKUN OD PA
Entity Type:Organization
Organization Name:NARIN PETIKUN OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETIKUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-293-7061
Mailing Address - Street 1:3652 EDEN DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 UPTOWN BLVD
Practice Address - Street 2:A
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-3508
Practice Address - Country:US
Practice Address - Phone:972-293-7061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179131101Medicaid
TX179131101Medicaid
00295YMedicare PIN