Healthcare Provider Details

I. General information

NPI: 1144859729
Provider Name (Legal Business Name): NICHOLAS PETRI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 JONATHAN LUCAS CSB 210, MSC 323
CHARLESTON SC
29425-6173
US

IV. Provider business mailing address

1765 CORNSILK DR
CHARLESTON SC
29414-8018
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1767
  • Fax:
Mailing address:
  • Phone: 919-280-1299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number83718
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number83718
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number83718
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: