Provider Demographics
NPI:1750729869
Name:PETKUS, AMY L (OD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:L
Last Name:PETKUS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:L
Other - Last Name:MORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2106 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2708
Practice Address - Country:US
Practice Address - Phone:219-464-8200
Practice Address - Fax:219-531-6804
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003794152W00000X
IL046.010656152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist