Healthcare Provider Details

I. General information

NPI: 1902837099
Provider Name (Legal Business Name): MICHELLE PETROFES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 RANCH RD
REEDSPORT OR
97467-1720
US

IV. Provider business mailing address

620 RANCH RD
REEDSPORT OR
97467-1720
US

V. Phone/Fax

Practice location:
  • Phone: 541-271-2163
  • Fax: 541-271-4058
Mailing address:
  • Phone: 541-271-2163
  • Fax: 541-271-4058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD14685
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: