Provider Demographics
NPI:1811987654
Name:PETRAKIAN, ALEXANDRE A (MD)
Entity type:Individual
Prefix:
First Name:ALEXANDRE
Middle Name:A
Last Name:PETRAKIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1783 TROUP HWY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-5869
Mailing Address - Country:US
Mailing Address - Phone:903-595-2283
Mailing Address - Fax:903-595-1063
Practice Address - Street 1:1783 TROUP HWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-595-2283
Practice Address - Fax:903-595-1063
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6234207R00000X, 207RC0000X, 207RI0011X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX045057901Medicaid
TX060060260OtherRAILROAD MEDICARE
TX87792YOtherBCBS OF TEXAS
TX045057901OtherSMITH COUNTY INDIGENT
LA1776521Medicaid
TX060060260OtherRAILROAD MEDICARE
TXH24852Medicare UPIN