Individual
DR. MAXWELL RUSKIN PETTIJOHN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
OPT-2856
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
026644
KAISER COMMERCIAL NUMBER
CO
05
—
07483015
—
CO
Enumeration date
07/12/2011
Last updated
05/20/2021
Update your record
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