Provider Demographics
NPI:1629464334
Name:PETKIEWICZ, STEPHANIE (MD PHD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PETKIEWICZ
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INNOVATION DR
Mailing Address - Street 2:BIOTECH 3
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-4307
Mailing Address - Country:US
Mailing Address - Phone:508-334-1000
Mailing Address - Fax:
Practice Address - Street 1:1 INNOVATION DR
Practice Address - Street 2:BIOTECH 3
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-4307
Practice Address - Country:US
Practice Address - Phone:508-334-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2015-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA263902207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology