Provider Demographics
NPI:1871578344
Name:PITTS, JEANETTE M (MD)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:M
Last Name:PITTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17510 W GRAND PKWY S STE 420
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-2173
Mailing Address - Country:US
Mailing Address - Phone:832-308-3470
Mailing Address - Fax:832-308-3471
Practice Address - Street 1:17510 W GRAND PKWY S STE 420
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2173
Practice Address - Country:US
Practice Address - Phone:832-308-3470
Practice Address - Fax:832-308-3471
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30913207N00000X
WI67706207N00000X
TXU1353207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ737265Medicaid
AZ86080015085259C301OtherTRIWEST
AZ070017561OtherRAILROAD MEDICARE
AZ86080015085259C301OtherTRIWEST
AZ737265Medicaid