Healthcare Provider Details

I. General information

NPI: 1144322421
Provider Name (Legal Business Name): TIMOTHY WILLIAM PETTITT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HENRY CLAY AVE
NEW ORLEANS LA
70118
US

IV. Provider business mailing address

200 HENRY CLAY AVE
NEW ORLEANS LA
70118
US

V. Phone/Fax

Practice location:
  • Phone: 504-896-9868
  • Fax: 504-896-9410
Mailing address:
  • Phone: 504-896-9868
  • Fax: 504-896-9410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number13143R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: