Provider Demographics
NPI:1902888019
Name:PETITJEAN, MARK C (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:PETITJEAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1307 CROWLEY RAYNE HWY
Mailing Address - Street 2:SUITE E
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526-8210
Mailing Address - Country:US
Mailing Address - Phone:337-788-0975
Mailing Address - Fax:337-788-3744
Practice Address - Street 1:1307 CROWLEY RAYNE HWY
Practice Address - Street 2:SUITE E
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-8210
Practice Address - Country:US
Practice Address - Phone:337-788-0975
Practice Address - Fax:337-788-3744
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA018518207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1913499Medicaid
LA1913499Medicaid
LAC78401Medicare UPIN