Basic Information
| Provider Information | |||||||||
| NPI: | 1427184134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETZAR | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | BUTLER | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1029 | ||||||||
| Address2: | |||||||||
| City: | SUMNER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983900190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063985906 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7500 MERCY RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681242319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023986184 | ||||||||
| FaxNumber: | 4023986702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | G53874 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 243275 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 60153757 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207ZB0001X | G53874 | CA | N | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZB0001X | 243275 | NY | N | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZB0001X | 60153757 | WA | N | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZH0000X | G53874 | CA | N | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZH0000X | 243275 | NY | N | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZH0000X | 60153757 | WA | N | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0102X | MD-40809 | IA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | G53874 | CA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 243275 | NY | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 60153757 | WA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 27112 | NE | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | RB2632 | 01 | NY | MEDICARE PTAN | OTHER |