Provider Demographics
NPI:1154351310
Name:PETTIGROVE, BRUCE BEN (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:BEN
Last Name:PETTIGROVE
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 1:2448 E 81ST ST STE 3700
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4257
Mailing Address - Country:US
Mailing Address - Phone:918-492-4122
Mailing Address - Fax:918-492-7451
Practice Address - Street 1:2448 E 81ST ST STE 3700
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4257
Practice Address - Country:US
Practice Address - Phone:918-492-4122
Practice Address - Fax:918-492-7451
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13121207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100089490AMedicaid
OK200020920 AMedicaid
OK200020920 AMedicaid