Provider Demographics
NPI:1033209937
Name:PETTYJOHN, JANET SUE (DO)
Entity Type:Individual
Prefix:DR
First Name:JANET
Middle Name:SUE
Last Name:PETTYJOHN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6302 BENJAMIN RD
Mailing Address - Street 2:SUITE # 410
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-5116
Mailing Address - Country:US
Mailing Address - Phone:813-639-9119
Mailing Address - Fax:813-639-1039
Practice Address - Street 1:6302 BENJAMIN RD
Practice Address - Street 2:SUITE # 410
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5116
Practice Address - Country:US
Practice Address - Phone:813-639-9119
Practice Address - Fax:813-639-1039
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3595207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057576300Medicaid
FL82066Medicare ID - Type Unspecified
FL057576300Medicaid