Provider Demographics
NPI:1508863960
Name:PETTY, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:PETTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4500 W NEWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2245
Mailing Address - Country:US
Mailing Address - Phone:352-336-6000
Mailing Address - Fax:352-332-0799
Practice Address - Street 1:4500 W NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2245
Practice Address - Country:US
Practice Address - Phone:352-336-6000
Practice Address - Fax:352-336-6078
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME67863207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43719ZMedicare PIN
FLG71318Medicare UPIN