Provider Demographics
NPI:1164732715
Name:PETTIT, JOHN DERRICK
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DERRICK
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 1:6800 NW 39TH AVE. LOT 486
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073
Mailing Address - Country:US
Mailing Address - Phone:740-205-7315
Mailing Address - Fax:
Practice Address - Street 1:6800 NW 39TH AVE. LOT 486
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073
Practice Address - Country:US
Practice Address - Phone:740-205-7315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSV743461171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor