Provider Demographics
NPI:1841422359
Name:PETTAWAY, GLENDA V (MD)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:V
Last Name:PETTAWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GLENDA
Other - Middle Name:V
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:215 N COLEMAN ST
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-3530
Mailing Address - Country:US
Mailing Address - Phone:478-237-2638
Mailing Address - Fax:478-237-9138
Practice Address - Street 1:215 N COLEMAN ST
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-3530
Practice Address - Country:US
Practice Address - Phone:478-237-2638
Practice Address - Fax:478-237-9138
Is Sole Proprietor?:No
Enumeration Date:2009-08-17
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062456208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000632376IMedicaid
GA269902777AMedicaid