Healthcare Provider Details

I. General information

NPI: 1104837293
Provider Name (Legal Business Name): CHRYSANTHE PETRAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 FULTON AVE STE 100
HEMPSTEAD NY
11550-3702
US

IV. Provider business mailing address

700 HICKSVILLE RD SUITE 204
BETHPAGE NY
11714-3471
US

V. Phone/Fax

Practice location:
  • Phone: 516-292-1034
  • Fax: 516-292-0565
Mailing address:
  • Phone: 516-576-5812
  • Fax: 516-576-5801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number190715-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number190715
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: