Provider Demographics
NPI:1477754513
Name:PETR, MICHAEL J (MD, PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:PETR
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7807 BAYMEADOWS RD E STE 208
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9666
Mailing Address - Country:US
Mailing Address - Phone:904-330-0302
Mailing Address - Fax:904-330-0418
Practice Address - Street 1:7807 BAYMEADOWS RD E STE 208
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9666
Practice Address - Country:US
Practice Address - Phone:904-446-9991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98433207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA749600040AMedicaid
FL2784815-00Medicaid
FLAE066YMedicare PIN
FLP00702886Medicare PIN
FLAE066ZMedicare PIN