Provider Demographics
NPI:1598247991
Name:PAVEL V PETRIK MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PAVEL V PETRIK MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAVEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:PETRIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-522-3256
Mailing Address - Street 1:PO BOX 8700
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93539-8700
Mailing Address - Country:US
Mailing Address - Phone:661-522-3256
Mailing Address - Fax:661-940-0206
Practice Address - Street 1:44725 10TH ST W STE 120
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3051
Practice Address - Country:US
Practice Address - Phone:661-522-3256
Practice Address - Fax:661-940-0206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-31
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74861208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA74861OtherCA MEDICAL LICENSE