Provider Demographics
NPI:1760442362
Name:PETTIT, WILLIAM J (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:PETTIT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-2705
Mailing Address - Country:US
Mailing Address - Phone:918-582-1980
Mailing Address - Fax:
Practice Address - Street 1:2345 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-2705
Practice Address - Country:US
Practice Address - Phone:918-582-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2146207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100174060CMedicaid
OK248228204Medicare PIN
OKD38571Medicare UPIN