Provider Demographics
NPI:1730107889
Name:PETTKE, MICHAEL BRANDON (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRANDON
Last Name:PETTKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 NW JOHN JONES DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-8040
Mailing Address - Country:US
Mailing Address - Phone:817-297-7100
Mailing Address - Fax:817-297-7193
Practice Address - Street 1:1320 NW JOHN JONES DR
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-8040
Practice Address - Country:US
Practice Address - Phone:817-297-7100
Practice Address - Fax:817-297-7193
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C0840Medicare PIN
TXV00455Medicare UPIN