Active NPI
Waymond Jay Pettit, M.D.
- Otolaryngology Physician
- Decatur, IL
National Provider Identifier
1679720726
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Otolaryngology Physician
- License
- 036051290
- Practice address
- 3620 S Taylor Rd
Decatur, IL 62521-9015 - Phone
- (217) 454-0022
- NPI assigned
- Aug 20, 2008
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Otolaryngology Physician | 207Y00000X | 036051290 | IL | Primary |
Addresses
Primary practice location
3620 S Taylor Rd
Decatur, IL 62521-9015
Mailing address
451 E 1000 N
La Porte, IN 46350-8638
Phone (219) 778-8524
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 036051290 | IL | MD | Otolaryngology Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1219190400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1219190400000",
"number": "1679720726",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "451 E 1000 N",
"city": "LA PORTE",
"state": "IN",
"postal_code": "463508638",
"telephone_number": "219-778-8524",
"fax_number": "219-778-8534"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3620 S TAYLOR RD",
"city": "DECATUR",
"state": "IL",
"postal_code": "625219015",
"telephone_number": "217-454-0022"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETTIT",
"first_name": "WAYMOND",
"middle_name": "JAY",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2008-08-20",
"last_updated": "2008-08-20",
"status": "A"
},
"taxonomies": [
{
"code": "207Y00000X",
"taxonomy_group": "",
"desc": "Otolaryngology",
"state": "IL",
"license": "036051290",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Decatur, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 20, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.