Provider Demographics
NPI:1659536068
Name:PETANI, JOSIP (MD)
Entity Type:Individual
Prefix:
First Name:JOSIP
Middle Name:
Last Name:PETANI
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:PO BOX 60
Mailing Address - Street 2:101 W LAKE ST
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48764-0060
Mailing Address - Country:US
Mailing Address - Phone:989-362-8617
Mailing Address - Fax:989-362-7309
Practice Address - Street 1:101 W. LAKE ST
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763
Practice Address - Country:US
Practice Address - Phone:989-362-8617
Practice Address - Fax:989-362-7309
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJP0LI6930208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2796045Medicaid
MIF13213Medicare UPIN