Healthcare Provider Details

I. General information

NPI: 1700366978
Provider Name (Legal Business Name): BRIAN PETTITT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 WATERS PL
BRONX NY
10461-2720
US

IV. Provider business mailing address

112 E 103RD ST APT 25
NEW YORK NY
10029-5318
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4800
  • Fax:
Mailing address:
  • Phone: 404-518-4679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: