Provider Demographics
NPI:1568508893
Name:PETROFSKI, JASON ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ALEXANDER
Last Name:PETROFSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 NORTHSIDE BLVD
Mailing Address - Street 2:SUITE 1900
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7623
Mailing Address - Country:US
Mailing Address - Phone:678-341-3764
Mailing Address - Fax:678-341-3769
Practice Address - Street 1:1505 NORTHSIDE BLVD
Practice Address - Street 2:SUITE 1900
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7623
Practice Address - Country:US
Practice Address - Phone:678-341-3764
Practice Address - Fax:678-341-3769
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059311208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA236918506AMedicaid
GA236918506EMedicaid
GA236918506DMedicaid
GA202I286867Medicare PIN
GA236918506DMedicaid