Provider Demographics
NPI:1053552745
Name:PETTEGREW, JONATHAN MATTHEW (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MATTHEW
Last Name:PETTEGREW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 E ORANGEBURG AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5512
Mailing Address - Country:US
Mailing Address - Phone:209-572-3224
Mailing Address - Fax:209-572-4528
Practice Address - Street 1:609 E ORANGEBURG AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5512
Practice Address - Country:US
Practice Address - Phone:209-572-3224
Practice Address - Fax:209-572-4528
Is Sole Proprietor?:No
Enumeration Date:2009-03-10
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A13395207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program