Provider Demographics
NPI:1912945338
Name:PETROU, CHRISTINA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:MARIE
Last Name:PETROU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:CHRISTINA
Other - Middle Name:MARIE
Other - Last Name:PETROU-HAEFS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1530 E GOODRICH LN
Mailing Address - Street 2:
Mailing Address - City:FOX POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53217-2951
Mailing Address - Country:US
Mailing Address - Phone:414-839-8379
Mailing Address - Fax:
Practice Address - Street 1:7040 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 420
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3885
Practice Address - Country:US
Practice Address - Phone:414-247-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2387152WC0802X
WI2387-035152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2718OtherPTAN
WI38575400Medicaid
WI0866110001Medicare NSC
WI2718001Medicare PIN
WI38575400Medicaid