Provider Demographics
NPI:1497739064
Name:PETRACO, JOHN GREGG (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GREGG
Last Name:PETRACO
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 1:118 N COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2120
Mailing Address - Country:US
Mailing Address - Phone:631-471-7171
Mailing Address - Fax:631-473-4605
Practice Address - Street 1:118 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2120
Practice Address - Country:US
Practice Address - Phone:631-471-7171
Practice Address - Fax:631-473-4605
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194289207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G22723Medicare UPIN
NY025431Medicare ID - Type Unspecified