Provider Demographics
NPI:1265468706
Name:PETTIJOHN, TRENT LEON (MD)
Entity Type:Individual
Prefix:DR
First Name:TRENT
Middle Name:LEON
Last Name:PETTIJOHN
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 1:6300 W PARKER RD
Mailing Address - Street 2:MOB II 125
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8100
Mailing Address - Country:US
Mailing Address - Phone:469-800-4400
Mailing Address - Fax:469-800-4410
Practice Address - Street 1:6300 W PARKER RD
Practice Address - Street 2:MOB II 125
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8100
Practice Address - Country:US
Practice Address - Phone:469-800-4400
Practice Address - Fax:469-800-4410
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4433207R00000X, 207RC0000X, 207U00000X, 207UN0901X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CX370OtherBCBSTX
TX036498603Medicaid
TX036498604Medicaid
TX036498602Medicaid
TX036498605Medicaid
TX8741N3Medicare PIN
TX8740N0Medicare PIN
TX8CX370OtherBCBSTX
TXTXB138365Medicare PIN
TX036498604Medicaid
TX8739N2Medicare PIN
TX060065698Medicare PIN
TX060065712Medicare PIN
TX036498605Medicaid