Provider Demographics
NPI:1225290208
Name:JOHN A. PETTIT, O.D.
Entity Type:Organization
Organization Name:JOHN A. PETTIT, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:9419-213-3411
Mailing Address - Street 1:3920 BEE RIDGE RD
Mailing Address - Street 2:BLDG. A SUITE A
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-1207
Mailing Address - Country:US
Mailing Address - Phone:941-923-3411
Mailing Address - Fax:941-921-3832
Practice Address - Street 1:3920 BEE RIDGE RD
Practice Address - Street 2:BLDG. A SUITE A
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-1207
Practice Address - Country:US
Practice Address - Phone:941-923-3411
Practice Address - Fax:941-921-3832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL086943100Medicaid
FL19968Medicare PIN
FLT84157Medicare UPIN
FL0557650002Medicare NSC