Basic Information
| Provider Information | |||||||||
| NPI: | 1215349642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETRO | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | NICOLAS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 W HAMPDEN AVE STE 105 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801102167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033414730 | ||||||||
| FaxNumber: | 3033414708 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 W HAMPDEN AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801102129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7209747464 | ||||||||
| FaxNumber: | 3039537274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2014 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | DR.0058113 | CO | N | Agencies | Home Health | 207QS0010X | DR.0058113 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | DR.0058113 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9000173212 | 05 | CO | MEDICAID |