Provider Demographics
NPI:1881665263
Name:PETTY, JOHN G (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:G
Last Name:PETTY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2423 E MAIN
Mailing Address - Street 2:STE 4
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321
Mailing Address - Country:US
Mailing Address - Phone:970-565-8809
Mailing Address - Fax:970-565-8881
Practice Address - Street 1:2423 E MAIN
Practice Address - Street 2:STE 4
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321
Practice Address - Country:US
Practice Address - Phone:970-565-8809
Practice Address - Fax:970-565-8881
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO35259207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01352590Medicaid
COC1841Medicare ID - Type Unspecified
G31659Medicare UPIN