Provider Demographics
NPI:1760469456
Name:PETRO, DIMITRI MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DIMITRI
Middle Name:MICHAEL
Last Name:PETRO
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 1:718 MCKEAN AVE
Mailing Address - Street 2:
Mailing Address - City:DONORA
Mailing Address - State:PA
Mailing Address - Zip Code:15033-1061
Mailing Address - Country:US
Mailing Address - Phone:724-379-4401
Mailing Address - Fax:724-379-4568
Practice Address - Street 1:718 MCKEAN AVE
Practice Address - Street 2:
Practice Address - City:DONORA
Practice Address - State:PA
Practice Address - Zip Code:15033-1061
Practice Address - Country:US
Practice Address - Phone:724-379-4401
Practice Address - Fax:724-379-4568
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027877L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA66097Other3 RIVERS HEALTH PLAN
PA250818OtherUPMC
PA0731177Medicaid
PA66097Other3 RIVERS HEALTH PLAN
PA0731177Medicaid