Provider Demographics
NPI:1124290515
Name:G TIMOTHY PETITO OD PA
Entity type:Organization
Organization Name:G TIMOTHY PETITO OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:PETITO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:727-578-9880
Mailing Address - Street 1:8695 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-3103
Mailing Address - Country:US
Mailing Address - Phone:727-578-9880
Mailing Address - Fax:727-578-1510
Practice Address - Street 1:8695 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-3103
Practice Address - Country:US
Practice Address - Phone:727-578-9880
Practice Address - Fax:727-578-1510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP0001955152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34170Medicare PIN