Provider Demographics
NPI:1265450175
Name:PETTIT, JAMES C (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:PETTIT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3721 HERWOL AVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-7218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 BRAZOS AVE
Practice Address - Street 2:
Practice Address - City:ROCKDALE
Practice Address - State:TX
Practice Address - Zip Code:76567-2517
Practice Address - Country:US
Practice Address - Phone:512-446-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9947207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8U8772OtherBCBS
TX140233137Medicaid
TX140233138Medicaid
TX140233138Medicaid
TX8C6048Medicare PIN
TX8G4358Medicare PIN
TXP00305392Medicare PIN