Healthcare Provider Details

I. General information

NPI: 1023185600
Provider Name (Legal Business Name): BARBARA JEAN PETTITT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 12/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD., NE SURGICAL EDUCATION OFFICE ROOM H-121
ATLANTA GA
30322
US

IV. Provider business mailing address

1364 CLIFTON RD., NE SURGICAL EDUCATION OFFICE ROOM H-121
ATLANTA GA
30322
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-1293
  • Fax: 404-712-0561
Mailing address:
  • Phone: 404-727-1293
  • Fax: 404-712-0561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number27629
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number27629
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: