Provider Demographics
NPI:1841244050
Name:PETRIDES, MARIAN (MD)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:PETRIDES
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 1:39 WILD TURKEY LN
Mailing Address - Street 2:
Mailing Address - City:WAITSFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05673-7348
Mailing Address - Country:US
Mailing Address - Phone:802-496-6175
Mailing Address - Fax:
Practice Address - Street 1:39 WILD TURKEY LN
Practice Address - Street 2:
Practice Address - City:WAITSFIELD
Practice Address - State:VT
Practice Address - Zip Code:05673-7348
Practice Address - Country:US
Practice Address - Phone:802-496-6175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0006038207ZB0001X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B58817Medicare UPIN