Provider Demographics
NPI:1316004831
Name:PETROULAKIS, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:PETROULAKIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 W 2ND PL
Mailing Address - Street 2:MONTEFIORE G100
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-1527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11600 W 2ND PL
Practice Address - Street 2:MONTEFIORE G100
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1527
Practice Address - Country:US
Practice Address - Phone:720-321-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO54158207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7062491OtherAETNA
NJJ9371OtherHORIZON BCBS
NJH06764Medicare UPIN
NJ7062491OtherAETNA