Provider Demographics
NPI:1427030162
Name:PETROFF, OGNEN A C (MD)
Entity Type:Individual
Prefix:
First Name:OGNEN
Middle Name:A C
Last Name:PETROFF
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 1:40 TEMPLE ST
Mailing Address - Street 2:SUITE 6-C
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-2715
Mailing Address - Country:US
Mailing Address - Phone:203-785-4085
Mailing Address - Fax:203-737-1597
Practice Address - Street 1:40 TEMPLE ST
Practice Address - Street 2:SUITE 6-C
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2715
Practice Address - Country:US
Practice Address - Phone:203-785-4085
Practice Address - Fax:203-737-1597
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0236512084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001236512Medicaid
D83615Medicare UPIN
CT130000160Medicare ID - Type Unspecified