Basic Information
| Provider Information | |||||||||
| NPI: | 1336287036 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROBERT M PETTIS MD INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7630 | ||||||||
| Address2: | |||||||||
| City: | LAGUNA NIGUEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926077630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496433345 | ||||||||
| FaxNumber: | 9496433560 | ||||||||
| Practice Location | |||||||||
| Address1: | 31862 COAST HWY STE 302 | ||||||||
| Address2: | |||||||||
| City: | LAGUNA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926516772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497150500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 07/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | PETTIS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9497150500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | A77461 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | A77461 | 01 | CA | STATE LICENSE | OTHER |