Provider Demographics
NPI:1790852200
Name:PETTIT, DUANE L (OD)
Entity Type:Individual
Prefix:DR
First Name:DUANE
Middle Name:L
Last Name:PETTIT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 N BELLFLOWER BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-1129
Mailing Address - Country:US
Mailing Address - Phone:562-497-2020
Mailing Address - Fax:
Practice Address - Street 1:2700 N BELLFLOWER BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-1129
Practice Address - Country:US
Practice Address - Phone:562-497-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 7307 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0771840001Medicare NSC
CAT 70186Medicare UPIN
CAOP7307Medicare PIN