MEDICARE: DR. PETR ITZHAK D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	234430	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801843412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETR ITZHAK D.O.

Provider Business Mailing Address
First Line	:	6805 MYRTLE AVE
Second Line	:
City	:	GLENDALE
State	:	NY
Zip	:	11385-7267
Country	:	US
Telephone Number	:	718-366-2242
Fax Number	:

Provider Business Practice Location Address
First Line	:	6805 MYRTLE AVE
Second Line	:
City	:	GLENDALE
State	:	NY
Zip	:	11385-7267
Country	:	US
Telephone Number	:	718-366-2242
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2006
Last Update Date	:	08/07/2007

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