Provider Demographics
NPI:1770627804
Name:MIKHAIL PETROV,O.D.,INC.
Entity Type:Organization
Organization Name:MIKHAIL PETROV,O.D.,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKHAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROV
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:614-436-9600
Mailing Address - Street 1:440 POLARIS PKWY
Mailing Address - Street 2:SUITE 325
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-6999
Mailing Address - Country:US
Mailing Address - Phone:614-436-9600
Mailing Address - Fax:614-259-6546
Practice Address - Street 1:440 POLARIS PKWY
Practice Address - Street 2:SUITE 325
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-6999
Practice Address - Country:US
Practice Address - Phone:614-436-9600
Practice Address - Fax:614-259-6546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4909152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2516263Medicaid
OH2516263Medicaid
OH2516263Medicaid
OH=========026OtherCARESOURCE