Provider Demographics
NPI:1932318797
Name:PETTRY, JOHN LEE (IDC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LEE
Last Name:PETTRY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 USS JAMES MADISON ROAD
Mailing Address - Street 2:BRANCH HEALTH CLINIC KINGS BAY
Mailing Address - City:KINGS BAY
Mailing Address - State:GA
Mailing Address - Zip Code:31547-2531
Mailing Address - Country:US
Mailing Address - Phone:912-573-2938
Mailing Address - Fax:
Practice Address - Street 1:881 USS JAMES MADISON ROAD
Practice Address - Street 2:BRANCH HEALTH CLINIC KINGS BAY
Practice Address - City:KINGS BAY
Practice Address - State:GA
Practice Address - Zip Code:31547-2531
Practice Address - Country:US
Practice Address - Phone:912-573-2938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman