Provider Demographics
NPI:1003251497
Name:PETRASEK, JAN (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JAN
Middle Name:
Last Name:PETRASEK
Suffix:
Gender:
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-4775
Mailing Address - Fax:601-815-0434
Practice Address - Street 1:5201 HARRY HINES BLVD
Practice Address - Street 2:GRADUATE MEDICAL EDUCATION
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7708
Practice Address - Country:US
Practice Address - Phone:214-590-8058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS27717207RG0100X, 207R00000X
TXBP10047494390200000X
TXQ8602207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program