Provider Demographics
NPI:1881859593
Name:CORWIN D. PETTY, MD, PA
Entity Type:Organization
Organization Name:CORWIN D. PETTY, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CORWIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-254-1005
Mailing Address - Street 1:3201 S MARKET ST STE 105
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8168
Mailing Address - Country:US
Mailing Address - Phone:479-254-1005
Mailing Address - Fax:479-668-4003
Practice Address - Street 1:3201 S MARKET ST STE 105
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8168
Practice Address - Country:US
Practice Address - Phone:479-254-1005
Practice Address - Fax:479-668-4003
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PETTY MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-22
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C680OtherBLUE CROSS BLUE SHIELD
AR149427002Medicaid
AR149427002Medicaid