Healthcare Provider Details

I. General information

NPI: 1265652242
Provider Name (Legal Business Name): MIKAEL PETROSYAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MICHIGAN AVE NW
WASHINGTON DC
20010-2916
US

IV. Provider business mailing address

111 MICHIGAN AVE NW
WASHINGTON DC
20010-2916
US

V. Phone/Fax

Practice location:
  • Phone: 202-476-2151
  • Fax:
Mailing address:
  • Phone: 818-859-3964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberD0076125
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: