Provider Demographics
NPI:1700850682
Name:PETTY, MICHAEL KENT (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENT
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:PO BOX 5338
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708
Mailing Address - Country:US
Mailing Address - Phone:254-202-4660
Mailing Address - Fax:254-202-4716
Practice Address - Street 1:7300 BOSQUE BLVD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710
Practice Address - Country:US
Practice Address - Phone:254-202-2600
Practice Address - Fax:254-202-2650
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A8890OtherBCBS
TX142060601Medicaid
TX142060601Medicaid
8387J4Medicare PIN
TX8387J4Medicare ID - Type Unspecified
080169110Medicare PIN