Provider Demographics
NPI:1851393748
Name:PETIT, JAMES MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:PETIT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J.M.
Other - Middle Name:
Other - Last Name:PETIT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:20 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-1755
Mailing Address - Country:US
Mailing Address - Phone:859-781-0431
Mailing Address - Fax:859-781-0473
Practice Address - Street 1:20 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-1755
Practice Address - Country:US
Practice Address - Phone:859-781-0431
Practice Address - Fax:859-781-0473
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY205282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64205289Medicaid
KYC74058Medicare UPIN
KY64205289Medicaid