Provider Demographics
NPI:1417044868
Name:PETRIK, PAVEL VACLAV (MD)
Entity Type:Individual
Prefix:
First Name:PAVEL
Middle Name:VACLAV
Last Name:PETRIK
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:PO BOX 8700
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93539-8700
Mailing Address - Country:US
Mailing Address - Phone:661-522-3256
Mailing Address - Fax:661-948-2006
Practice Address - Street 1:44725 10TH ST W STE 120
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3051
Practice Address - Country:US
Practice Address - Phone:661-522-3256
Practice Address - Fax:661-948-2006
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74861208G00000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0091800Medicaid
F44060Medicare UPIN
CAWG74861CMedicare ID - Type Unspecified