Healthcare Provider Details

I. General information

NPI: 1003251497
Provider Name (Legal Business Name): JAN PETRASEK M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2013
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 HARRY HINES BLVD GRADUATE MEDICAL EDUCATION
DALLAS TX
75235-7708
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 214-590-8058
  • Fax:
Mailing address:
  • Phone: 601-815-4775
  • Fax: 601-815-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number27717
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number27717
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10047494
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberQ8602
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: