Provider Demographics
NPI:1225044936
Name:PETTIT, GEORGE WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WALTER
Last Name:PETTIT
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 1:15814 CASCADING BROOK WAY
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-5558
Mailing Address - Country:US
Mailing Address - Phone:713-253-4216
Mailing Address - Fax:
Practice Address - Street 1:11411 FM 1960 RD W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-3610
Practice Address - Country:US
Practice Address - Phone:281-890-0792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9946207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G7966OtherBCBSTX PROVIDER NUMBER
TX8G7966OtherBCBSTX PROVIDER NUMBER
A83148Medicare UPIN
TXP00416211Medicare PIN