Provider Demographics
NPI:1104861160
Name:PETTY, GLENN G (DPM)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:G
Last Name:PETTY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6579
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-6579
Mailing Address - Country:US
Mailing Address - Phone:870-863-7080
Mailing Address - Fax:903-792-3286
Practice Address - Street 1:5510 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1822
Practice Address - Country:US
Practice Address - Phone:903-792-2710
Practice Address - Fax:903-831-7357
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR180213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018576101Medicaid
TXP00349253OtherRAILROAD-TX
AR134175717Medicaid
ARP00129576OtherRAILROAD-AR
TX00204EMedicare PIN
AR5T941Medicare PIN
6077990001Medicare NSC
TXP00349253OtherRAILROAD-TX