Provider Demographics
NPI:1083798060
Name:PETTIS, OPAL E (MD)
Entity Type:Individual
Prefix:DR
First Name:OPAL
Middle Name:E
Last Name:PETTIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:OPAL
Other - Middle Name:E
Other - Last Name:THORNTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:2301 M ST NW
Practice Address - Street 2:KAISER PERMANENTE NORTHWEST DC MEDICAL CENTER
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-1427
Practice Address - Country:US
Practice Address - Phone:202-419-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC0423432084P0800X
CAA480652084P0804X
DCMD0423432084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A480650Medicaid
F06819Medicare UPIN
00A480650Medicare ID - Type Unspecified