Provider Demographics
NPI:1770700163
Name:PETTIFORD, COURTNEY KATRIL (MD)
Entity type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:KATRIL
Last Name:PETTIFORD
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 1:122 GEORGE ST.
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2641
Mailing Address - Country:US
Mailing Address - Phone:304-250-0382
Mailing Address - Fax:304-250-0383
Practice Address - Street 1:122 GEORGE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2641
Practice Address - Country:US
Practice Address - Phone:304-250-0382
Practice Address - Fax:304-250-0383
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64715208600000X
WV24518208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery