Provider Demographics
NPI:1396836086
Name:PETROFF, NINA (MD)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:PETROFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23250 CHAGRIN BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5470
Mailing Address - Country:US
Mailing Address - Phone:216-765-7474
Mailing Address - Fax:216-765-7484
Practice Address - Street 1:23250 CHAGRIN BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5470
Practice Address - Country:US
Practice Address - Phone:216-765-7474
Practice Address - Fax:216-765-7484
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051014P207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0866684Medicaid
OH76428Medicare UPIN
OH0866684Medicaid