Provider Demographics
NPI:1265449508
Name:PETRANEK, MICHAEL LLOYD (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LLOYD
Last Name:PETRANEK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9918 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3901
Mailing Address - Country:US
Mailing Address - Phone:703-273-9818
Mailing Address - Fax:866-453-6775
Practice Address - Street 1:9918 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3901
Practice Address - Country:US
Practice Address - Phone:703-273-9818
Practice Address - Fax:866-453-6775
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC507213ES0103X
VA0103300947213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905009Medicaid
NC4557050001Medicare NSC