Healthcare Provider Details

I. General information

NPI: 1891884433
Provider Name (Legal Business Name): THOMAS CHRISTOPHER PETTINGER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14413 EAST SANDS RANCH ROAD
VAIL AZ
85641-8876
US

IV. Provider business mailing address

14413 EAST SANDS RANCH ROAD
VAIL AZ
85641-8876
US

V. Phone/Fax

Practice location:
  • Phone: 520-661-6089
  • Fax: 520-561-8493
Mailing address:
  • Phone: 520-661-6089
  • Fax: 520-561-8493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A4257
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1515
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: