Provider Demographics
NPI:1831128644
Name:PETREY, LAURA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PETREY
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 1:3701 JUNIUS ST
Mailing Address - Street 2:CS11 G006
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2026
Mailing Address - Country:US
Mailing Address - Phone:214-821-1599
Mailing Address - Fax:214-821-8985
Practice Address - Street 1:2710 SWISS AVENUE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-5900
Practice Address - Country:US
Practice Address - Phone:214-821-1599
Practice Address - Fax:214-821-8985
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL28242086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148514601Medicaid
TX8934N0Medicare ID - Type Unspecified
TXH51213Medicare UPIN