Provider Demographics
NPI:1093007825
Name:PETRIK, EDWARD WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:WAYNE
Last Name:PETRIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 LIVE OAK ST
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-1238
Mailing Address - Country:US
Mailing Address - Phone:737-293-0000
Mailing Address - Fax:
Practice Address - Street 1:3004 LIVE OAK ST
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-1238
Practice Address - Country:US
Practice Address - Phone:737-293-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4098207LC0200X, 2083A0100X, 208D00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice