Provider Demographics
NPI:1407937253
Name:PETTIT, JOHN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:PETTIT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:340 BIRCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1782
Mailing Address - Country:US
Mailing Address - Phone:360-671-9197
Mailing Address - Fax:360-676-7730
Practice Address - Street 1:340 BIRCHWOOD AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1782
Practice Address - Country:US
Practice Address - Phone:360-671-9197
Practice Address - Fax:360-676-7730
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00024911208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1032978Medicaid
WAA09511Medicare UPIN
WA8864658Medicare PIN
WA1032978Medicaid