Provider Demographics
NPI:1841464120
Name:PETTUS, JASON R (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:R
Last Name:PETTUS
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:ONE MEDICAL CENTER DR
Mailing Address - Street 2:DARTMOUTH-HITCHCOCK MEDICAL CENTER, DEPT. OF PATHOLOGY
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-650-5000
Mailing Address - Fax:
Practice Address - Street 1:ONE MEDICAL CENTER DR
Practice Address - Street 2:DARTMOUTH-HITCHCOCK MEDICAL CENTER, DEPT. OF PATHOLOGY
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-650-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA250580207ZP0102X
NH16131207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1021925Medicaid
NH3086997Medicaid
VT1021925Medicaid