Provider Demographics
NPI:1861493157
Name:PETAK, STEVEN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:MICHAEL
Last Name:PETAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6550 FANNIN ST
Mailing Address - Street 2:SUITE 1101
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2717
Mailing Address - Country:US
Mailing Address - Phone:713-441-0006
Mailing Address - Fax:
Practice Address - Street 1:6550 FANNIN ST
Practice Address - Street 2:SUITE 1101
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2717
Practice Address - Country:US
Practice Address - Phone:713-441-0006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1147207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1861493157OtherBLUE CROSS BLUE SHIELD
TX119141304Medicaid
TXP01242674OtherMEDICARE RR
TX119141305Medicaid
C20442Medicare UPIN
TX119141304Medicaid
TX279722YKWUMedicare PIN
892893Medicare ID - Type Unspecified