Provider Demographics
NPI:1912101593
Name:PETITT, MATTHEW SEAN (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SEAN
Last Name:PETITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 CRENSHAW RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77504-3628
Mailing Address - Country:US
Mailing Address - Phone:281-991-5944
Mailing Address - Fax:
Practice Address - Street 1:4419 CRENSHAW RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-3628
Practice Address - Country:US
Practice Address - Phone:281-991-5944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2750207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
3853003243OtherMYUTMB 3853003243-COMMERCIAL NUMBER
TXTXB124785Medicare PIN