Provider Demographics
NPI:1760676100
Name:PETRO, MARJORIE GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARJORIE
Middle Name:GRACE
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 1:37 IVAN HILL ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2001
Mailing Address - Country:US
Mailing Address - Phone:860-423-9764
Mailing Address - Fax:860-423-9866
Practice Address - Street 1:37 IVAN HILL ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2001
Practice Address - Country:US
Practice Address - Phone:860-423-9764
Practice Address - Fax:860-423-9866
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT19844207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B39110Medicare UPIN