Provider Demographics
NPI:1750329744
Name:PETRAK-RON, BETTY A (MD)
Entity type:Individual
Prefix:DR
First Name:BETTY
Middle Name:A
Last Name:PETRAK-RON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S MCCASLIN BLVD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-9731
Mailing Address - Country:US
Mailing Address - Phone:720-890-9904
Mailing Address - Fax:720-890-1440
Practice Address - Street 1:400 S MCCASLIN BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9731
Practice Address - Country:US
Practice Address - Phone:720-890-9904
Practice Address - Fax:720-890-1440
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0038190174400000X, 207K00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO23309334Medicaid
COC803630Medicare PIN
CO23309334Medicaid