Provider Demographics
NPI:1427040757
Name:PETRO, GEORGE C (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:C
Last Name:PETRO
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 1:625 BELLE TERRE RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2316
Mailing Address - Country:US
Mailing Address - Phone:631-473-4753
Mailing Address - Fax:631-473-4760
Practice Address - Street 1:625 BELLE TERRE RD
Practice Address - Street 2:SUITE 205
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2316
Practice Address - Country:US
Practice Address - Phone:631-473-4753
Practice Address - Fax:631-473-4760
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1453362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00660802Medicaid
A42967Medicare UPIN
NY00660802Medicaid