Provider Demographics
NPI:1124027628
Name:PETTY, JERRY MILLER (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:MILLER
Last Name:PETTY
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 1:225 BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3109
Mailing Address - Country:US
Mailing Address - Phone:704-376-1605
Mailing Address - Fax:704-335-8448
Practice Address - Street 1:225 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3109
Practice Address - Country:US
Practice Address - Phone:704-376-1605
Practice Address - Fax:704-335-8448
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11925207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
140004695OtherRAILROAD MEDICARE
SC453681Medicaid
NC8967385Medicaid
SC453681Medicaid
NC8967385Medicaid