Provider Demographics
NPI:1265591606
Name:PETRAKIS, STEVEN JOHN (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:JOHN
Last Name:PETRAKIS
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 1:500 NORTH MUNDO
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-1010
Mailing Address - Country:US
Mailing Address - Phone:575-759-3291
Mailing Address - Fax:575-759-7294
Practice Address - Street 1:500 NORTH MUNDO
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-2725
Practice Address - Country:US
Practice Address - Phone:575-759-3291
Practice Address - Fax:575-759-7294
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM96-117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM8HN067OtherMEDICARE PTAN #
NMK3526Medicaid
NM000S5584OtherMEDICAID PROVIDER #
NMHSZ196OtherMEDICARE PART B #
NM320057Medicare Oscar/Certification