Provider Demographics
NPI:1588666499
Name:PETTY, REGAN SKYE (OD)
Entity Type:Individual
Prefix:DR
First Name:REGAN
Middle Name:SKYE
Last Name:PETTY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DAWN DR
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72719-9314
Mailing Address - Country:US
Mailing Address - Phone:479-795-1411
Mailing Address - Fax:479-795-1412
Practice Address - Street 1:101 DAWN DR
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719
Practice Address - Country:US
Practice Address - Phone:479-426-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2567152W00000X
MO2005020659152W00000X
OK2463152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR160482722Medicaid
AR1588666499Medicaid