Provider Demographics
NPI:1790740249
Name:PETROS, TERESA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:MARIE
Last Name:PETROS
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 1:2365 FLINT CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6345
Mailing Address - Country:US
Mailing Address - Phone:678-513-4464
Mailing Address - Fax:
Practice Address - Street 1:2660 SATELLITE BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5803
Practice Address - Country:US
Practice Address - Phone:404-785-8330
Practice Address - Fax:404-785-8390
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037334208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
E58574Medicare UPIN