Provider Demographics
NPI:1184628547
Name:PETIT, MITCHELL ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:ROBERT
Last Name:PETIT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 W SWANN AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4617
Mailing Address - Country:US
Mailing Address - Phone:813-908-2020
Mailing Address - Fax:813-908-2133
Practice Address - Street 1:2000 66TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-4710
Practice Address - Country:US
Practice Address - Phone:727-341-1987
Practice Address - Fax:727-347-7297
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3419152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261355OtherCLARITY VISION PLAN
FL593651926OtherALLIED EYECARE
FL11436OtherSPECTERA
FL487101OtherNVA
FL3419OtherECPA
FL261355OtherCOLE VISION PLAN
FL410001004OtherHUMANA
FLVFL000856OtherAVESIS
FL620670100Medicaid
FL433332Medicare UPIN
FL261355OtherCLARITY VISION PLAN