Provider Demographics
NPI:1659395739
Name:PETRO, KATHLEEN R (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:R
Last Name:PETRO
Suffix:
Gender:F
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:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:2921 TELESTAR CT
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-1205
Practice Address - Country:US
Practice Address - Phone:703-280-5858
Practice Address - Fax:703-849-0874
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0056845208G00000X
VA0101248624208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC021602900Medicaid
MD906001401Medicaid
DC006928J19Medicare ID - Type Unspecified
MD906001401Medicaid