Provider Demographics
NPI:1659454544
Name:PETTIT, KELLY R (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
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 1:275 E 200 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2002
Mailing Address - Country:US
Mailing Address - Phone:800-366-1884
Mailing Address - Fax:
Practice Address - Street 1:1253 NW CANAL BLVD
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1334
Practice Address - Country:US
Practice Address - Phone:541-548-8131
Practice Address - Fax:541-526-6608
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0194207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMI19998Medicare UPIN