Basic Information
| Provider Information | |||||||||
| NPI: | 1831128644 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PETREY | ||||||||
| FirstName: | LAURA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 JUNIUS ST | ||||||||
| Address2: | CS11 G006 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752462026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148211599 | ||||||||
| FaxNumber: | 2148218985 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 SWISS AVENUE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752045900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148211599 | ||||||||
| FaxNumber: | 2148218985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 09/28/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | L2824 | TX | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 148514601 | 05 | TX | MEDICAID |