Provider Demographics
NPI:1801911359
Name:SOPHIA B. PETKOV, M.D.
Entity type:Organization
Organization Name:SOPHIA B. PETKOV, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:PETKOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-831-3310
Mailing Address - Street 1:75 POWHATTON DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-1661
Mailing Address - Country:US
Mailing Address - Phone:513-831-3310
Mailing Address - Fax:513-831-3311
Practice Address - Street 1:75 POWHATTON DR
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-1661
Practice Address - Country:US
Practice Address - Phone:513-831-3310
Practice Address - Fax:513-831-3311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH36901OtherHUMANA CHOICE CARE
OH000000006898OtherANTHEM BC-BS
OH0247638Medicaid
OH645595OtherAETNA
OH0247638Medicaid
OHA74970Medicare UPIN