Provider Demographics
NPI:1265653992
Name:PETRIE, DAVID EARL (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EARL
Last Name:PETRIE
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:PO BOX 356
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-0356
Mailing Address - Country:US
Mailing Address - Phone:800-374-5326
Mailing Address - Fax:
Practice Address - Street 1:929 N SAINT FRANCIS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3821
Practice Address - Country:US
Practice Address - Phone:800-374-5326
Practice Address - Fax:800-374-7656
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6367207L00000X
KS0432621207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200608960AMedicaid
KSP00727381OtherRR MEDICARE GROUP# CQ2302
KS200608960AMedicaid