Healthcare Provider Details

I. General information

NPI: 1861464810
Provider Name (Legal Business Name): TINA PETOK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8220 UNIVERSITY EXEC PARK DR SUITE 107
CHARLOTTE NC
28262-3380
US

IV. Provider business mailing address

8220 UNIVERSITY EXEC PARK DR STE 107
CHARLOTTE NC
28262-3380
US

V. Phone/Fax

Practice location:
  • Phone: 704-548-1221
  • Fax: 704-548-1311
Mailing address:
  • Phone: 704-548-1221
  • Fax: 704-548-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number32417
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: