Provider Demographics
NPI:1497795496
Name:PETTY, ROBERT T (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:PETTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:866 DONNER AVE
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-7136
Mailing Address - Country:US
Mailing Address - Phone:360-708-7940
Mailing Address - Fax:
Practice Address - Street 1:866 DONNER AVE
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-7136
Practice Address - Country:US
Practice Address - Phone:360-708-7940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO00001542207P00000X
CA20A 4256282N00000X
WAOP1542282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3075PEOtherBSWA
WA0209144OtherLIWA
WA8214223Medicaid
WA0209144OtherLIWA
WAE32891Medicare UPIN
WAP00319317Medicare PIN