Provider Demographics
NPI:1508829359
Name:PETKOVIC, BARBARA LYNN (DPM)
Entity Type:Individual
Prefix:DR
First Name:BARBARA
Middle Name:LYNN
Last Name:PETKOVIC
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6200 PLEASANT AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4670
Mailing Address - Country:US
Mailing Address - Phone:513-829-9333
Mailing Address - Fax:513-858-7827
Practice Address - Street 1:6200 PLEASANT AVE
Practice Address - Street 2:STE 3
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-4670
Practice Address - Country:US
Practice Address - Phone:513-829-9333
Practice Address - Fax:513-858-7827
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003284213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2323444Medicaid
OH4071941Medicare PIN
OHU89457Medicare UPIN