Healthcare Provider Details

I. General information

NPI: 1528300878
Provider Name (Legal Business Name): TATYANA PETUKHOVA M.D., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 WILLIAM ST FL 11
NEW YORK NY
10038-5323
US

IV. Provider business mailing address

3301 C ST STE 1300 UC DAVIS DEPARTMENT OF DERMATOLOGY
SACRAMENTO CA
95816-3370
US

V. Phone/Fax

Practice location:
  • Phone: 646-962-3376
  • Fax:
Mailing address:
  • Phone: 408-885-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA131981
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number293685
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number293685
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: