Provider Demographics
NPI:1629004999
Name:PETITO, GUY TIMOTHY (OD)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:TIMOTHY
Last Name:PETITO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8695 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-3103
Mailing Address - Country:US
Mailing Address - Phone:727-578-9880
Mailing Address - Fax:
Practice Address - Street 1:8695 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-3103
Practice Address - Country:US
Practice Address - Phone:727-578-9880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP-0001955152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT93319Medicare UPIN
FL19881Medicare ID - Type Unspecified