Healthcare Provider Details

I. General information

NPI: 1588731954
Provider Name (Legal Business Name): JANA PETRA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WATERMAN WAY
TAVARES FL
32778-5266
US

IV. Provider business mailing address

421 SE ALFRED MARKHAM ST
LAKE CITY FL
32025-2204
US

V. Phone/Fax

Practice location:
  • Phone: 352-253-3333
  • Fax:
Mailing address:
  • Phone: 386-697-1364
  • Fax: 888-370-3379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01051788A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME103317
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: