Provider Demographics
NPI:1336132489
Name:PETROSKI, DONALD (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:PETROSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:1113 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 305
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046
Practice Address - Country:US
Practice Address - Phone:609-835-3624
Practice Address - Fax:609-835-3628
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD012651E207R00000X, 207RG0100X
NJ25MA029690207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1123203Medicaid
D18722Medicare UPIN
NJ154482C04Medicare PIN