Provider Demographics
NPI:1487662631
Name:PETTINGER, CLAIR L (MD)
Entity Type:Individual
Prefix:
First Name:CLAIR
Middle Name:L
Last Name:PETTINGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NATE
Other - Middle Name:
Other - Last Name:PETTINGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4707 GREENLEAF CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8733
Mailing Address - Country:US
Mailing Address - Phone:209-338-1550
Mailing Address - Fax:209-545-2404
Practice Address - Street 1:4707 GREENLEAF CT
Practice Address - Street 2:SUITE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8733
Practice Address - Country:US
Practice Address - Phone:209-338-1550
Practice Address - Fax:209-545-2404
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29874207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABB729XMedicare PIN
CA00G298746Medicare PIN
CAA44204Medicare UPIN