Provider Demographics
NPI:1407979313
Name:PETTAY, MARK EDGAR (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDGAR
Last Name:PETTAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-1184
Mailing Address - Country:US
Mailing Address - Phone:614-836-7227
Mailing Address - Fax:614-836-3038
Practice Address - Street 1:495 MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-1184
Practice Address - Country:US
Practice Address - Phone:614-836-7227
Practice Address - Fax:614-836-3038
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1755111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH311462245OtherTAX ID