Provider Demographics
NPI:1437163607
Name:PETTY, JEFFREY SCOTT (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SCOTT
Last Name:PETTY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3229 W 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-4817
Mailing Address - Country:US
Mailing Address - Phone:903-872-9910
Mailing Address - Fax:903-874-8829
Practice Address - Street 1:3229 W 7TH AVE
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-4817
Practice Address - Country:US
Practice Address - Phone:903-872-9910
Practice Address - Fax:903-874-8829
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1499213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018605802Medicaid
P00339471OtherRR MCR
TX8W4430OtherBC/BS
TX480028382OtherRAILROAD INS.
5826920001Medicare NSC
TX018605802Medicaid
TX8F3533Medicare PIN
5353150001Medicare NSC
TXP00150689Medicare PIN