Provider Demographics
NPI:1134323769
Name:PETROPOULOS, JOE (PTA)
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:
Last Name:PETROPOULOS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2669 SHANNON ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-6343
Mailing Address - Country:US
Mailing Address - Phone:904-312-1321
Mailing Address - Fax:
Practice Address - Street 1:1422 SAN MARCO BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8536
Practice Address - Country:US
Practice Address - Phone:904-398-4133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA13537225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant