Provider Demographics
NPI:1609861004
Name:PETROSOVA, INNA (MD)
Entity type:Individual
Prefix:
First Name:INNA
Middle Name:
Last Name:PETROSOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 NOSTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-3029
Mailing Address - Country:US
Mailing Address - Phone:718-258-3777
Mailing Address - Fax:718-258-6284
Practice Address - Street 1:2233 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-3029
Practice Address - Country:US
Practice Address - Phone:718-258-3777
Practice Address - Fax:718-258-6284
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216610207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY850761Medicare ID - Type Unspecified
NY850761Medicare UPIN
NYH19433Medicare UPIN