Basic Information
| Provider Information | |||||||||
| NPI: | 1134423387 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETIT | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | SEAN WILLIAM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETIT | ||||||||
| OtherFirstName: | THOMAS | ||||||||
| OtherMiddleName: | SEAN WILLIAM | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6101 BLUE LAGOON DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331263168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055002000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 460 N UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330246720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544374004 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2011 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA21355 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207R00000X | ME144317 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.