Healthcare Provider Details

I. General information

NPI: 1912945338
Provider Name (Legal Business Name): CHRISTINA MARIE PETROU O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINA MARIE PETROU-HAEFS O.D.

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7040 N PORT WASHINGTON RD SUITE 420
GLENDALE WI
53217-3885
US

IV. Provider business mailing address

1530 E GOODRICH LN
FOX POINT WI
53217-2951
US

V. Phone/Fax

Practice location:
  • Phone: 414-247-2020
  • Fax:
Mailing address:
  • Phone: 414-839-8379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2387-035
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2387
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number2387-035
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: