MEDICARE: DR. THERON M 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
1	207R00000X	Internal Medicine Physician	C175441	CA
2	207R00000X	Internal Medicine Physician	ME91576	FL
3	207R00000X	Internal Medicine Physician	MD61603161	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	64060	OTHER		BCBSFL

General Provider Information

NPI Number	:	1245214279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERON M PETTIT MD

Provider Business Mailing Address
First Line	:	700 NE 87TH AVE
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98664-4896
Country	:	US
Telephone Number	:	407-864-3051
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 NE 87TH AVE
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98664-4896
Country	:	US
Telephone Number	:	407-864-3051
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	04/01/2025

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