Provider Demographics
NPI:1154124287
Name:PETTWAY, MARKIA LENISE (DO)
Entity type:Individual
Prefix:
First Name:MARKIA
Middle Name:LENISE
Last Name:PETTWAY
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:857 CAMMACK RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35211-5961
Mailing Address - Country:US
Mailing Address - Phone:205-410-2540
Mailing Address - Fax:
Practice Address - Street 1:3860 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2460
Practice Address - Country:US
Practice Address - Phone:872-588-3016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program