Healthcare Provider Details

I. General information

NPI: 1336287036
Provider Name (Legal Business Name): ROBERT M PETTIS MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31862 COAST HWY STE 302
LAGUNA BEACH CA
92651-6772
US

IV. Provider business mailing address

PO BOX 7630
LAGUNA NIGUEL CA
92607-7630
US

V. Phone/Fax

Practice location:
  • Phone: 949-715-0500
  • Fax:
Mailing address:
  • Phone: 949-643-3345
  • Fax: 949-643-3560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA77461
License Number StateCA

VIII. Authorized Official

Name: ROBERT M PETTIS
Title or Position: PRESIDENT
Credential: MD
Phone: 949-715-0500