Provider Demographics
NPI:1356599526
Name:PETKO, EDWARD (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:PETKO
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 1:4955 VAN NUYS BLVD
Mailing Address - Street 2:ROOM 411
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1801
Mailing Address - Country:US
Mailing Address - Phone:818-990-1734
Mailing Address - Fax:
Practice Address - Street 1:4955 VAN NUYS BLVD
Practice Address - Street 2:ROOM 411
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1801
Practice Address - Country:US
Practice Address - Phone:818-990-1734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21856207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA21856Medicare PIN
CAA22800Medicare UPIN