Provider Demographics
NPI:1376624742
Name:UTRATA, PETR (MD)
Entity Type:Individual
Prefix:
First Name:PETR
Middle Name:
Last Name:UTRATA
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 1:19100 CREST AVE APT 24
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-2863
Mailing Address - Country:US
Mailing Address - Phone:510-357-1830
Mailing Address - Fax:510-274-5503
Practice Address - Street 1:19100 CREST AVE APT 24
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-2863
Practice Address - Country:US
Practice Address - Phone:650-288-8344
Practice Address - Fax:510-274-5503
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54495207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG19034Medicare UPIN
00A544950Medicare ID - Type Unspecified