Provider Demographics
NPI:1528055209
Name:PETTUS, MARK C (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:PETTUS
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 1:138 PATRICIA AVE
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:MA
Mailing Address - Zip Code:01226-2045
Mailing Address - Country:US
Mailing Address - Phone:413-684-2305
Mailing Address - Fax:
Practice Address - Street 1:3578 TOOMER KILN CIR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-9260
Practice Address - Country:US
Practice Address - Phone:843-884-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28214207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology