Healthcare Provider Details

I. General information

NPI: 1457079097
Provider Name (Legal Business Name): ALEXANDER JONATHAN PETTS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E CHICAGO AVE
CHICAGO IL
60611-4296
US

IV. Provider business mailing address

77 W HURON ST APT 613
CHICAGO IL
60654-3888
US

V. Phone/Fax

Practice location:
  • Phone: 312-503-8144
  • Fax:
Mailing address:
  • Phone: 405-308-5213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number125.087514
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: