Provider Demographics
NPI:1942378872
Name:PETKOV, BORIANA I (MD)
Entity Type:Individual
Prefix:DR
First Name:BORIANA
Middle Name:I
Last Name:PETKOV
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 1:424 W STATE HIGHWAY 5
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1723
Mailing Address - Country:US
Mailing Address - Phone:952-442-4461
Mailing Address - Fax:
Practice Address - Street 1:424 W STATE HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1723
Practice Address - Country:US
Practice Address - Phone:952-442-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2015-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEEC-06-1083208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery