Provider Demographics
NPI:1538142526
Name:PETIKUN, NARIN (OD)
Entity Type:Individual
Prefix:
First Name:NARIN
Middle Name:
Last Name:PETIKUN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3652 EDEN DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 UPTOWN BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-3508
Practice Address - Country:US
Practice Address - Phone:972-293-7061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5746152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179132901Medicaid
TX8D2370Medicare ID - Type Unspecified