Provider Demographics
NPI:1326047531
Name:PETTIT, REID ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:REID
Middle Name:ALLEN
Last Name:PETTIT
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 1:320 N LADD ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-1612
Mailing Address - Country:US
Mailing Address - Phone:815-842-4304
Mailing Address - Fax:845-844-5495
Practice Address - Street 1:320 N LADD ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-1612
Practice Address - Country:US
Practice Address - Phone:815-842-4304
Practice Address - Fax:845-844-5495
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007222152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
046-007222OtherOSF
4991920001OtherDME
IL499192011OtherMEDICARE DURABLE MEDICAL
IL05332011OtherBLUE CROSS
046-007222OtherLIC
05332011OtherBLUE CROSS
IL046-007222Medicaid
T37728OtherVSP
004036OtherHEALTH ALLIANCE
P00125958OtherRAILROAD
P00125958OtherRAILROAD
004036OtherHEALTH ALLIANCE
IL05332011OtherBLUE CROSS
IL046-007222Medicaid