1487713335 NPI number — DR. JOHN ALGREN PETTIT O.D.

Table of content: DR. JOHN ALGREN PETTIT O.D. (NPI 1487713335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487713335 NPI number — DR. JOHN ALGREN PETTIT O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTIT
Provider First Name:
JOHN
Provider Middle Name:
ALGREN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487713335
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1230 CORNISH CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34232-3042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-377-4417
Provider Business Mailing Address Fax Number:
941-918-2679

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1480 US HIGHWAY 17 N
Provider Second Line Business Practice Location Address:
INSIDE WALMART VISION
Provider Business Practice Location Address City Name:
WAUCHULA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33873-5006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-448-3790
Provider Business Practice Location Address Fax Number:
941-918-2679
Provider Enumeration Date:
12/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1551 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 086943100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 024263000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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