Provider Demographics
NPI:1487642450
Name:PETTEY, WILLIAM ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ROBERT
Last Name:PETTEY
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 1:6100 HARRIS PKWY
Mailing Address - Street 2:#390
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4124
Mailing Address - Country:US
Mailing Address - Phone:817-370-9011
Mailing Address - Fax:817-346-0380
Practice Address - Street 1:6100 HARRIS PKWY
Practice Address - Street 2:#390
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4124
Practice Address - Country:US
Practice Address - Phone:817-370-9011
Practice Address - Fax:817-346-0380
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8340207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
4254295OtherAETNA
91159OtherAETNA
TX131434601Medicaid
91159OtherAETNA