MEDICARE: ERIC WAYNE PETTYJOHN 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	207QS0010X	Sports Medicine (Family Medicine) Physician	ME156239	FL

General Provider Information

NPI Number	:	1356846299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC WAYNE PETTYJOHN MD

Provider Business Mailing Address
First Line	:	265 E ROLLINS ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-5502
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1141 PATTERSON TER
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-2203
Country	:	US
Telephone Number	:	844-407-4070
Fax Number	:	407-743-3050

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

Provider Enumeration Date	:	03/23/2018
Last Update Date	:	01/12/2026

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