Basic Information
| Provider Information | |||||||||
| NPI: | 1730611484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETRO | ||||||||
| FirstName: | KAROLINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUKALA | ||||||||
| OtherFirstName: | KAROLINA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 33 LEWIS RD FL 2 | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139051055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077700025 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10-42 MITCHELL AVE | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139031617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077622468 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2017 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25MA10796200 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 316746 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.