Provider Demographics
NPI:1568451540
Name:PETTERSON, SYLVIA R (MDPA)
Entity Type:Individual
Prefix:DR
First Name:SYLVIA
Middle Name:R
Last Name:PETTERSON
Suffix:
Gender:F
Credentials:MDPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NE 24TH CT
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-7642
Mailing Address - Country:US
Mailing Address - Phone:561-394-5432
Mailing Address - Fax:
Practice Address - Street 1:350 NE 24TH CT
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-7642
Practice Address - Country:US
Practice Address - Phone:561-394-5432
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 28197174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC7833Medicare UPIN
FL31084Medicare ID - Type UnspecifiedMEDICARE FL