Provider Demographics
NPI:1427082346
Name:PETTIS, ROBERT M (MD, MSPH, FACS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:PETTIS
Suffix:
Gender:M
Credentials:MD, MSPH, FACS
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 53970
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92619-3970
Mailing Address - Country:US
Mailing Address - Phone:497-150-5009
Mailing Address - Fax:949-337-4464
Practice Address - Street 1:16100 SAND CANYON AVE STE 230
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3730
Practice Address - Country:US
Practice Address - Phone:949-715-0500
Practice Address - Fax:949-337-4464
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA77461207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology