Provider Demographics
NPI:1043541725
Name:PETTIFORD, JANINE NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:JANINE
Middle Name:NICOLE
Last Name:PETTIFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:33 UPPER RIVERDALE ROAD SW
Mailing Address - Street 2:SUITE 112
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1627
Mailing Address - Country:US
Mailing Address - Phone:770-996-3190
Mailing Address - Fax:
Practice Address - Street 1:325 NORTH JEFF DAVIS DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:770-461-1337
Practice Address - Fax:770-461-0922
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-20
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXBP10023659208600000X
MO2010013505208600000X
GA072414208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I021079Medicare PIN