Provider Demographics
NPI:1467744573
Name:PETTIBON, KEITH (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:PETTIBON
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 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3146
Mailing Address - Country:US
Mailing Address - Phone:817-321-0404
Mailing Address - Fax:
Practice Address - Street 1:815 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-321-0404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-07
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR16142085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology