Provider Demographics
NPI:1073605085
Name:PETRY, GARY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:PETRY
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 1:1110 COLUMBINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:HOLTON
Mailing Address - State:KS
Mailing Address - Zip Code:66436
Mailing Address - Country:US
Mailing Address - Phone:785-364-2126
Mailing Address - Fax:785-364-2801
Practice Address - Street 1:1110 COLUMBINE DRIVE
Practice Address - Street 2:
Practice Address - City:HOLTON
Practice Address - State:KS
Practice Address - Zip Code:66436
Practice Address - Country:US
Practice Address - Phone:785-364-2126
Practice Address - Fax:785-364-2801
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0428470207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS80175101OtherRR MEDICARE
KS10039800AMedicaid
KS101003OtherBCBS
KSH06038Medicare UPIN
KS101003OtherBCBS