Provider Demographics
NPI:1447296298
Name:PETTIT, KENNETH LEE (DO)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:PETTIT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:40 S KYRENE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-4675
Mailing Address - Country:US
Mailing Address - Phone:480-706-0174
Mailing Address - Fax:480-706-0117
Practice Address - Street 1:40 S KYRENE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-4675
Practice Address - Country:US
Practice Address - Phone:480-706-0174
Practice Address - Fax:480-706-0117
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ3144207Q00000X, 2083P0011X
HIE07166207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ437609Medicaid
AZ76530Medicare ID - Type Unspecified
AZ81346Medicare ID - Type Unspecified
AZ437609Medicaid