Provider Demographics
NPI:1467419317
Name:PETTETT, PHILIP GARY (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:GARY
Last Name:PETTETT
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 1:8540 N ARNOLD PALMER DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-9595
Mailing Address - Country:US
Mailing Address - Phone:816-206-0397
Mailing Address - Fax:
Practice Address - Street 1:8540 N ARNOLD PALMER DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85742-9595
Practice Address - Country:US
Practice Address - Phone:816-206-0397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1029612080N0001X
KS04-244462080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100147450AMedicaid
MO203725403Medicaid
MO203725403Medicaid
MO2694448Medicare ID - Type Unspecified