Healthcare Provider Details

I. General information

NPI: 1649189226
Provider Name (Legal Business Name): MICHAEL STEVEN PETRIK MSC, OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 WASHINGTON ST STE 102
DEDHAM MA
02026-6715
US

IV. Provider business mailing address

701 HARRISON AVE UNIT 1244
BLAINE WA
98231-7061
US

V. Phone/Fax

Practice location:
  • Phone: 954-592-0052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD60328326
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: