Provider Demographics
NPI:1093277840
Name:PETTIT, CORY
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:PETTIT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:THE OHIO STATE UNIVERSTY WEXNER MEDICAL CENTER
Mailing Address - Street 2:395 W 12TH AVE, 3RD FLOOR
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210
Mailing Address - Country:US
Mailing Address - Phone:614-293-3989
Mailing Address - Fax:614-293-9789
Practice Address - Street 1:430 ALTAIR PKWY STE 210
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-7647
Practice Address - Country:US
Practice Address - Phone:614-898-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.147858207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology