Provider Demographics
NPI:1215046974
Name:PETTENGILL, MATTHEW (DPM)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PETTENGILL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31001-0698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0698
Mailing Address - Country:US
Mailing Address - Phone:602-263-1200
Mailing Address - Fax:602-200-5383
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:602-200-5383
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD1049213ES0103X
PASC004785L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0307600OtherBCBS
AZ046148Medicaid
AZ030078Medicare Oscar/Certification
AZ046148Medicaid
AZV00511Medicare UPIN