Provider Demographics
NPI:1629030622
Name:PETAKOV, DRAGAN S (MD)
Entity Type:Individual
Prefix:
First Name:DRAGAN
Middle Name:S
Last Name:PETAKOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 VARNUM AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854
Mailing Address - Country:US
Mailing Address - Phone:978-452-9700
Mailing Address - Fax:978-441-6075
Practice Address - Street 1:275 VARNUM AVE
Practice Address - Street 2:STE 201
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854
Practice Address - Country:US
Practice Address - Phone:978-452-9700
Practice Address - Fax:978-441-6075
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA157347207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0160750Medicaid
MAJ24518OtherBLUE SHIELD
MA0158658Medicaid
H14343Medicare UPIN
MAJ24518OtherBLUE SHIELD
MA0160750Medicaid