Provider Demographics
NPI:1518499946
Name:PETRENKO, DIMITRY MIKHAYLOVICH (DO)
Entity Type:Individual
Prefix:
First Name:DIMITRY
Middle Name:MIKHAYLOVICH
Last Name:PETRENKO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 KEISER BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-3333
Mailing Address - Country:US
Mailing Address - Phone:610-685-5864
Mailing Address - Fax:610-929-1528
Practice Address - Street 1:1250 S CEDAR CREST BLVD STE 205
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6271
Practice Address - Country:US
Practice Address - Phone:610-402-9116
Practice Address - Fax:610-402-9610
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS021386207RC0200X, 207RP1001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program