Provider Demographics
NPI:1487173514
Name:PETTIT, ALLY (OD)
Entity type:Individual
Prefix:
First Name:ALLY
Middle Name:
Last Name:PETTIT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 JOHN R RD STE 150
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-5859
Mailing Address - Country:US
Mailing Address - Phone:248-588-9300
Mailing Address - Fax:
Practice Address - Street 1:735 JOHN R RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5856
Practice Address - Country:US
Practice Address - Phone:248-951-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6574152W00000X
MI4901005425152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0279325Medicaid
MI1487173514Medicaid