Provider Demographics
NPI:1164632139
Name:PETROV, MIKHAIL (OD)
Entity Type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:PETROV
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2358 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209-2422
Mailing Address - Country:US
Mailing Address - Phone:614-235-9393
Mailing Address - Fax:614-235-6363
Practice Address - Street 1:2358 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43209-2422
Practice Address - Country:US
Practice Address - Phone:614-235-9393
Practice Address - Fax:614-235-6363
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4909152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2516263Medicaid
OHPE4122061Medicare ID - Type Unspecified
OH2516263Medicaid