Healthcare Provider Details

I. General information

NPI: 1417044868
Provider Name (Legal Business Name): PAVEL VACLAV PETRIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44725 10TH ST W STE 120
LANCASTER CA
93534-3051
US

IV. Provider business mailing address

PO BOX 8700
LANCASTER CA
93539-8700
US

V. Phone/Fax

Practice location:
  • Phone: 661-522-3256
  • Fax: 661-948-2006
Mailing address:
  • Phone: 661-522-3256
  • Fax: 661-948-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberG74861
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberG74861
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: