Provider Demographics
NPI:1881704831
Name:PETROV, OLEG (DPM)
Entity type:Individual
Prefix:DR
First Name:OLEG
Middle Name:
Last Name:PETROV
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N WABASH AVE
Mailing Address - Street 2:SUITE 1914
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1903
Mailing Address - Country:US
Mailing Address - Phone:312-641-2999
Mailing Address - Fax:312-641-6534
Practice Address - Street 1:111 N WABASH AVE
Practice Address - Street 2:SUITE 1914
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1903
Practice Address - Country:US
Practice Address - Phone:312-641-2999
Practice Address - Fax:312-641-6534
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16-3074213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT36982Medicare UPIN
IL650590Medicare ID - Type Unspecified