Healthcare Provider Details

I. General information

NPI: 1457836678
Provider Name (Legal Business Name): VALLEY ORTHOPAEDIC BONE AND JOINT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 E ORANGEBURG AVE STE 201
MODESTO CA
95350-5512
US

IV. Provider business mailing address

609 E ORANGEBURG AVE STE 201
MODESTO CA
95350-5512
US

V. Phone/Fax

Practice location:
  • Phone: 209-572-3224
  • Fax: 209-572-4528
Mailing address:
  • Phone: 209-572-3224
  • Fax: 209-572-4528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN MATTHEW PETTEGREW
Title or Position: SURGEON/PARTNER
Credential: D.O.
Phone: 209-572-3224