Provider Demographics
NPI:1194827865
Name:PETITT, KIMBERLY DENISE (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DENISE
Last Name:PETITT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 POST OAK PLACE DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-3164
Mailing Address - Country:US
Mailing Address - Phone:713-960-8008
Mailing Address - Fax:713-960-0965
Practice Address - Street 1:4545 POST OAK PLACE DR
Practice Address - Street 2:SUITE 130
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-3164
Practice Address - Country:US
Practice Address - Phone:713-960-8008
Practice Address - Fax:713-960-0965
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4912208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1194827865OtherTRICARE SOUTH
TX8CJ367OtherBCBSTX
TX188605302Medicaid
TX8CJ367OtherBCBSTX
TX188605302Medicaid
TX1194827865OtherTRICARE SOUTH
TXTXB103396Medicare PIN
TXCI5830Medicare PIN
TXP00432024Medicare PIN
TX8J8930Medicare PIN
TX1194827865Medicare PIN
TXP00843416Medicare PIN