Healthcare Provider Details

I. General information

NPI: 1942308473
Provider Name (Legal Business Name): WILLIAM ALFRED PETTIT III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: WILLIAM PETTIT MD

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 GEKELER LANE
LA GRANDE OR
97850
US

IV. Provider business mailing address

1404 GEKELER LANE
LA GRANDE OR
97850
US

V. Phone/Fax

Practice location:
  • Phone: 541-963-3119
  • Fax: 541-963-3110
Mailing address:
  • Phone: 541-963-3119
  • Fax: 541-963-3110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number17635
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: