Provider Demographics
NPI:1245214279
Name:PETTIT, THERON M (MD)
Entity Type:Individual
Prefix:
First Name:THERON
Middle Name:M
Last Name:PETTIT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5540 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-1668
Mailing Address - Country:US
Mailing Address - Phone:407-367-4706
Mailing Address - Fax:321-203-4606
Practice Address - Street 1:5540 E GRANT ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-1668
Practice Address - Country:US
Practice Address - Phone:407-367-4706
Practice Address - Fax:321-203-4606
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91576207R00000X
CAC175441207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272039600Medicaid
64060OtherBCBSFL
64060OtherBCBSFL
FL64060ZMedicare PIN