Provider Demographics
NPI:1912198979
Name:PEWITT, JONATHAN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:PEWITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 COGBURN AVENUE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1010
Mailing Address - Country:US
Mailing Address - Phone:770-422-8815
Mailing Address - Fax:770-422-8816
Practice Address - Street 1:835 COGBURN AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1008
Practice Address - Country:US
Practice Address - Phone:770-422-5557
Practice Address - Fax:770-422-5456
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065413207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU003108826AMedicaid
GU003108826AMedicaid