Provider Demographics
NPI:1801228630
Name:PETTYJOHN, EDWARD WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:WALTER
Last Name:PETTYJOHN
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 1:15311 ESCARPMENT OAK
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-5155
Mailing Address - Country:US
Mailing Address - Phone:770-653-7413
Mailing Address - Fax:
Practice Address - Street 1:9110 N LOOP 1604 W STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-3397
Practice Address - Country:US
Practice Address - Phone:210-802-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS1430207XS0117X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX400888001Medicaid