Provider Demographics
NPI:1023177862
Name:PETTIGREW, RODERIC IVAN (MD)
Entity type:Individual
Prefix:DR
First Name:RODERIC
Middle Name:IVAN
Last Name:PETTIGREW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5204 W CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-1547
Mailing Address - Country:US
Mailing Address - Phone:240-476-5899
Mailing Address - Fax:
Practice Address - Street 1:1364 CLIFTON RD NE
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1059
Practice Address - Country:US
Practice Address - Phone:404-712-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027106207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine