Provider Demographics
NPI:1982923652
Name:PETRIDES, JOHN S
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:S
Last Name:PETRIDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2385 APPLETON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-7105
Mailing Address - Country:US
Mailing Address - Phone:662-449-8280
Mailing Address - Fax:
Practice Address - Street 1:5699 GETWELL RD
Practice Address - Street 2:BUILDING E, SUITE 2
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-7312
Practice Address - Country:US
Practice Address - Phone:662-349-6712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3548225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPT3548OtherPT LICENSE: MISSISSIPPI