Provider Demographics
NPI:1871555375
Name:PETTIS, KARLTON SHEA (MD)
Entity type:Individual
Prefix:
First Name:KARLTON
Middle Name:SHEA
Last Name:PETTIS
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 1:700 S TORRENCE ST
Mailing Address - Street 2:STE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3077
Mailing Address - Country:US
Mailing Address - Phone:704-372-9393
Mailing Address - Fax:704-372-0135
Practice Address - Street 1:700 S TORRENCE ST
Practice Address - Street 2:STE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3077
Practice Address - Country:US
Practice Address - Phone:704-372-9393
Practice Address - Fax:704-372-0135
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2025155OtherMEDICARE LEGACY NUMBER
FL89136C1Medicaid
FL2025155OtherMEDICARE LEGACY NUMBER