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NPI Code Detail

MEDICARE: JODY L PETTIT MD

MEDICARE: JODY L PETTIT MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine PhysicianMD20585OR

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1110153060OTHERORRR MEDICARE

General Provider Information

NPI Number : 1063447100
Entity Type Code : Individual
Provider Name (Legal Business Name) : JODY L PETTIT MD
Provider Business Mailing Address
First Line : 800 SW 13TH AVE
Second Line :
City : PORTLAND
State : OR
Zip : 97205-1902
Country : US
Telephone Number : 503-221-0161
Fax Number :
Provider Business Practice Location Address
First Line : 800 SW 13TH AVE
Second Line :
City : PORTLAND
State : OR
Zip : 97205-1902
Country : US
Telephone Number : 503-221-0161
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/11/2006
Last Update Date : 07/21/2022

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