Provider Demographics
NPI:1629051677
Name:PETTEY, ADAM ADAIR (MD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:ADAIR
Last Name:PETTEY
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 1:1600 EUREKA RD
Mailing Address - Street 2:DEPARTMENT OF DERMATOLOGY
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3027
Mailing Address - Country:US
Mailing Address - Phone:916-771-6662
Mailing Address - Fax:
Practice Address - Street 1:2120 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3700
Practice Address - Country:US
Practice Address - Phone:916-771-6662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90875207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL48701OtherBLUECROSS/BLUESHIELD
FL48701ZMedicare ID - Type Unspecified
FLI15926Medicare UPIN