Healthcare Provider Details

I. General information

NPI: 1265591606
Provider Name (Legal Business Name): STEVEN JOHN PETRAKIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 NORTH MUNDO
DULCE NM
87528-2725
US

IV. Provider business mailing address

500 NORTH MUNDO
DULCE NM
87528-1010
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-3291
  • Fax: 575-759-7294
Mailing address:
  • Phone: 575-759-3291
  • Fax: 575-759-7294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNM96-117
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: