Provider Demographics
NPI:1679761159
Name:PETTIT, BOBBY J
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:J
Last Name:PETTIT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5830 W THUNDERBIRD RD STE B5
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4655
Mailing Address - Country:US
Mailing Address - Phone:602-841-7886
Mailing Address - Fax:
Practice Address - Street 1:5830 W THUNDERBIRD RD STE B5
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4655
Practice Address - Country:US
Practice Address - Phone:602-841-7886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ644156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0841580001Medicare NSC