Provider Demographics
NPI:1679720726
Name:PETTIT, WAYMOND JAY (MD)
Entity type:Individual
Prefix:DR
First Name:WAYMOND
Middle Name:JAY
Last Name:PETTIT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 E 1000 N
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-8638
Mailing Address - Country:US
Mailing Address - Phone:219-778-8524
Mailing Address - Fax:219-778-8534
Practice Address - Street 1:3620 S TAYLOR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-9015
Practice Address - Country:US
Practice Address - Phone:217-454-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036051290207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology