Provider Demographics
NPI:1497992432
Name:PETITT, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:PETITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4036 CEDARHURST DR APT 101
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-6412
Mailing Address - Country:US
Mailing Address - Phone:805-406-0880
Mailing Address - Fax:
Practice Address - Street 1:5075 S BRADLEY RD
Practice Address - Street 2:SUITE 131
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-5077
Practice Address - Country:US
Practice Address - Phone:805-938-7444
Practice Address - Fax:805-938-7422
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine