Provider Demographics
NPI:1194221648
Name:PETRASH, CARSON COPE
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:COPE
Last Name:PETRASH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 S ZARZAMORA ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-5209
Mailing Address - Country:US
Mailing Address - Phone:210-358-7600
Mailing Address - Fax:
Practice Address - Street 1:701 S ZARZAMORA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-5209
Practice Address - Country:US
Practice Address - Phone:210-358-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXU4600207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX36379873OtherTEXAS DRIVERS LICENSE