Provider Demographics
NPI:1891218442
Name:PETTIBONE, MARGARET (MD)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:
Last Name:PETTIBONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14445 OLIVE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-1437
Mailing Address - Country:US
Mailing Address - Phone:747-210-3000
Mailing Address - Fax:
Practice Address - Street 1:14445 OLIVE VIEW DR
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1437
Practice Address - Country:US
Practice Address - Phone:747-210-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTL110302084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty