Provider Demographics
NPI:1265750129
Name:PETROVA, EKATERINA NIKOLAEVNA (MD)
Entity type:Individual
Prefix:
First Name:EKATERINA
Middle Name:NIKOLAEVNA
Last Name:PETROVA
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 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6805
Mailing Address - Country:US
Mailing Address - Phone:209-384-6493
Mailing Address - Fax:209-383-1296
Practice Address - Street 1:1510 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4437
Practice Address - Country:US
Practice Address - Phone:209-549-7090
Practice Address - Fax:209-549-7099
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0011975208000000X
CAA127080208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics