Healthcare Provider Details

I. General information

NPI: 1013497213
Provider Name (Legal Business Name): ANDREY PETRIKOVETS MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3312 GLENDALE BLVD
LOS ANGELES CA
90039-1813
US

IV. Provider business mailing address

PO BOX 39466
LOS ANGELES CA
90039-0466
US

V. Phone/Fax

Practice location:
  • Phone: 888-487-6496
  • Fax: 323-250-1361
Mailing address:
  • Phone: 888-487-6496
  • Fax: 323-250-1361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberA127810
License Number StateCA

VIII. Authorized Official

Name: ANDREY PETRIKOVETS
Title or Position: OWNER
Credential: MD
Phone: 888-487-6496