Provider Demographics
NPI:1477754513
Name:PETR, MICHAEL J (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:PETR
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 PRUDENTIAL DR
Mailing Address - Street 2:TOWER B, 11TH FLOOR
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8202
Mailing Address - Country:US
Mailing Address - Phone:904-388-6518
Mailing Address - Fax:904-384-1005
Practice Address - Street 1:7807 BAYMEADOWS RD E STE 208
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9666
Practice Address - Country:US
Practice Address - Phone:904-446-9991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98433207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2784815-00Medicaid
GA749600040AMedicaid
FLAE066YMedicare PIN
FLP00702886Medicare PIN
FLAE066ZMedicare PIN