Provider Demographics
NPI:1265655757
Name:PETTY, LAURENCE MILTON (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:MILTON
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 1:8508 ALAFIA HILLS DR
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33567-3408
Mailing Address - Country:US
Mailing Address - Phone:813-650-8600
Mailing Address - Fax:813-650-8664
Practice Address - Street 1:8508 ALAFIA HILLS DR
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33567-3408
Practice Address - Country:US
Practice Address - Phone:813-650-8600
Practice Address - Fax:813-650-8664
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068819207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255973100Medicaid
FLE91974Medicare UPIN
FL255973100Medicaid