Provider Demographics
NPI:1356362396
Name:ANGELO A PETROPOLIS MD PLLC
Entity type:Organization
Organization Name:ANGELO A PETROPOLIS MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KAPLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-458-6331
Mailing Address - Street 1:1916 PASEO SAN LUIS
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-4614
Mailing Address - Country:US
Mailing Address - Phone:520-458-1505
Mailing Address - Fax:520-458-6949
Practice Address - Street 1:1916 PASEO SAN LUIS
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-4614
Practice Address - Country:US
Practice Address - Phone:520-458-1505
Practice Address - Fax:520-458-6949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22192207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ325242Medicaid
AZAZ0776240OtherBCBSAZ
AZG18247Medicare UPIN
AZ325242Medicaid
AZZ104014Medicare PIN