Provider Demographics
NPI:1669428439
Name:PETROKUBI, ROBERT J (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:PETROKUBI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12500 MAYO CT
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9159
Mailing Address - Country:US
Mailing Address - Phone:502-228-2793
Mailing Address - Fax:502-228-2793
Practice Address - Street 1:12500 MAYO CT
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-9159
Practice Address - Country:US
Practice Address - Phone:502-228-2793
Practice Address - Fax:502-228-2793
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30771207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64307713Medicaid
KY64307713Medicaid
KY110191025Medicare PIN
KY00546179Medicare Oscar/Certification