Provider Demographics
NPI:1508818261
Name:PETRI, CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:PETRI
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 1:116 PORTER DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-8527
Mailing Address - Country:US
Mailing Address - Phone:802-388-9885
Mailing Address - Fax:802-388-7120
Practice Address - Street 1:116 PORTER DR
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-8527
Practice Address - Country:US
Practice Address - Phone:802-388-9885
Practice Address - Fax:802-388-7120
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420007280208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002513Medicaid
VTD03185Medicare UPIN
VT0002513Medicaid