Provider Demographics
NPI:1871547505
Name:PETROVAS, DEMETRIOS (MD)
Entity type:Individual
Prefix:MR
First Name:DEMETRIOS
Middle Name:
Last Name:PETROVAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-2267
Mailing Address - Country:US
Mailing Address - Phone:773-658-2300
Mailing Address - Fax:773-658-2305
Practice Address - Street 1:3960 N. HARLEM AVE.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634
Practice Address - Country:US
Practice Address - Phone:773-658-2300
Practice Address - Fax:773-658-2305
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36084958207R00000X
CAA50087207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36084958Medicaid
IL36084958Medicaid
987862001Medicare PIN