Provider Demographics
NPI:1518071174
Name:PETTIT, ROBERT JOHN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:PETTIT
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 1:3430 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7579
Mailing Address - Country:US
Mailing Address - Phone:208-523-3060
Mailing Address - Fax:208-523-0028
Practice Address - Street 1:3430 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7579
Practice Address - Country:US
Practice Address - Phone:208-523-3060
Practice Address - Fax:208-523-0028
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6067208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0117419Medicaid
WY114945800Medicaid
ID000010005951OtherBLUE SHIELD
WY1285786046Medicaid
ID002298200Medicaid
ID10678OtherBLUE CROSS
ID002298200Medicaid