Provider Demographics
NPI:1639599194
Name:PETIOTE, FREDELY (MD)
Entity Type:Individual
Prefix:MR
First Name:FREDELY
Middle Name:
Last Name:PETIOTE
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 1:1001 TOWSON AVE OFC
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-4921
Mailing Address - Country:US
Mailing Address - Phone:479-441-5005
Mailing Address - Fax:479-441-4917
Practice Address - Street 1:1001 TOWSON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4921
Practice Address - Country:US
Practice Address - Phone:479-441-5005
Practice Address - Fax:479-441-4917
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME161341207R00000X
ARE-10781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine