Provider Demographics
NPI:1700655149
Name:PETZ, COLLIN JOHN
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:JOHN
Last Name:PETZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37450 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1082
Mailing Address - Country:US
Mailing Address - Phone:734-458-4601
Mailing Address - Fax:
Practice Address - Street 1:26650 EUREKA RD STE A
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-4835
Practice Address - Country:US
Practice Address - Phone:313-389-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program