Provider Demographics
NPI:1083807333
Name:PETTUS, JOSEPH ATKINS IV (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ATKINS
Last Name:PETTUS
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 ADAMS ST SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3709
Mailing Address - Country:US
Mailing Address - Phone:256-536-9020
Mailing Address - Fax:256-536-9020
Practice Address - Street 1:825 ADAMS ST SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3709
Practice Address - Country:US
Practice Address - Phone:256-536-9020
Practice Address - Fax:256-536-9020
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-01225208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC147WJOtherBCBS
VA1083807333Medicaid
WV3810010766Medicaid
NC5908269Medicaid
SCQ25008Medicaid
NC812207OtherPARTNERS
NC204388OtherMEDCOST
WV3810010766Medicaid