Provider Demographics
NPI:1255306783
Name:PETTIFORD, BRIAN L (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:PETTIFORD
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:1514 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121-2429
Practice Address - Country:US
Practice Address - Phone:504-842-3966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD417309208G00000X, 208600000X
LAMD206806208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA20091811OtherAMERIHEALTH MERCY-WMG
MS01034231Medicaid
LA2371461Medicaid
PA1541821OtherGATEWAY-WMG
MD037212900Medicaid
PA101094283Medicaid
PA1628981OtherHIGHMARK BLUE SHIELD
PA280433OtherUNISON-WMG
MD953505OtherCAREFIRST MD BCBS
PA081916FLTMedicare PIN
LA363978YH3UMedicare PIN
PA081916FKYMedicare PIN
PAP00913843Medicare PIN
PA1541821OtherGATEWAY-WMG