Provider Demographics
NPI:1942279013
Name:PETTY, GARY J (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
Last Name:PETTY
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 1:1600 MEDICAL CENTER DR STE 1500
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3657
Mailing Address - Country:US
Mailing Address - Phone:304-691-1199
Mailing Address - Fax:
Practice Address - Street 1:659 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504
Practice Address - Country:US
Practice Address - Phone:304-736-5247
Practice Address - Fax:304-736-7367
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-5727207Q00000X
IL036118847207Q00000X
WI50755020207Q00000X
WV17521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1804764000Medicaid
OH000000699790OtherANTHEM
OHP00693880OtherRRMCR
OH000000593893OtherANTHEM
OH2255250Medicaid
OH1804764000Medicaid
OHP00693880OtherRRMCR
OH000000699790OtherANTHEM