Provider Demographics
NPI:1710911748
Name:PETITGOUT, CRAIG MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:MICHAEL
Last Name:PETITGOUT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 22ND AVE # 3
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-1565
Mailing Address - Country:US
Mailing Address - Phone:319-354-9574
Mailing Address - Fax:319-834-1128
Practice Address - Street 1:850 22ND AVE # 3
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-1565
Practice Address - Country:US
Practice Address - Phone:319-354-9574
Practice Address - Fax:319-834-1128
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA06076111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0160606Medicaid
IA41165Medicare PIN
IA0160606Medicaid