Provider Demographics
NPI:1356846299
Name:PETTYJOHN, ERIC WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:WAYNE
Last Name:PETTYJOHN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:267-339-7843
Mailing Address - Fax:267-339-3761
Practice Address - Street 1:1141 PATTERSON TER
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2203
Practice Address - Country:US
Practice Address - Phone:844-407-4070
Practice Address - Fax:407-743-3050
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME156239207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine