Provider Demographics
NPI:1023089562
Name:PETROSOVA, TATYANA (MD)
Entity type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:PETROSOVA
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:PO BOX 653
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63006-0653
Mailing Address - Country:US
Mailing Address - Phone:314-797-7074
Mailing Address - Fax:314-227-5505
Practice Address - Street 1:10420 OLD OLIVE STREET RD STE 305
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5914
Practice Address - Country:US
Practice Address - Phone:314-797-7074
Practice Address - Fax:314-227-5505
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2024-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002007108207RN0300X
IL036107203207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207235706Medicaid
H78623Medicare UPIN
MO207235706Medicaid