Provider Demographics
NPI:1659334043
Name:PETTAY, JAMES B (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:B
Last Name:PETTAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LOCUST ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44302-1821
Mailing Address - Country:US
Mailing Address - Phone:330-253-7753
Mailing Address - Fax:330-253-4611
Practice Address - Street 1:300 LOCUST ST
Practice Address - Street 2:SUITE 200
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44302-1821
Practice Address - Country:US
Practice Address - Phone:330-253-7753
Practice Address - Fax:330-253-4611
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35082415P208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2424148Medicaid