Provider Demographics
NPI:1407045644
Name:PETTEWAY, ANITA (MD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:PETTEWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 N MIAMI BEACH BLVD
Mailing Address - Street 2:SUITE 503
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3712
Mailing Address - Country:US
Mailing Address - Phone:305-944-8887
Mailing Address - Fax:
Practice Address - Street 1:909 N MIAMI BEACH BLVD
Practice Address - Street 2:SUITE 503
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3712
Practice Address - Country:US
Practice Address - Phone:305-944-8887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69729207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3421617OtherCIGNA
FL31947OtherBLUE CROSS BLUE SHIELD
FL250632700Medicaid
FL259904OtherAVMED
FL2054109OtherAETNA
FL25649OtherNHP
FL259904OtherAVMED