Provider Demographics
NPI:1245214279
Name:PETTIT, THERON M (MD)
Entity type:Individual
Prefix:DR
First Name:THERON
Middle Name:M
Last Name:PETTIT
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-4896
Mailing Address - Country:US
Mailing Address - Phone:407-864-3051
Mailing Address - Fax:
Practice Address - Street 1:700 NE 87TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-4896
Practice Address - Country:US
Practice Address - Phone:407-864-3051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC175441207R00000X
FLME91576207R00000X
WAMD61603161207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272039600Medicaid
64060OtherBCBSFL
64060OtherBCBSFL
FL64060ZMedicare PIN