Healthcare Provider Details

I. General information

NPI: 1679641609
Provider Name (Legal Business Name): KEVIN PETTUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7786 LEXINGTON RD
LANCASTER KY
40444-9119
US

IV. Provider business mailing address

PO BOX 2185
DANVILLE KY
40423-2185
US

V. Phone/Fax

Practice location:
  • Phone: 859-548-4114
  • Fax: 859-548-2718
Mailing address:
  • Phone: 859-548-4114
  • Fax: 859-548-2718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number41148
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01056257A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41148
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: