Provider Demographics
NPI:1982628533
Name:JEFFREY PETTY, DPM, PA
Entity Type:Organization
Organization Name:JEFFREY PETTY, DPM, PA
Other - Org Name:CORSICANA FOOT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:903-872-9910
Mailing Address - Street 1:PO BOX 1774
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75151-1774
Mailing Address - Country:US
Mailing Address - Phone:903-872-9910
Mailing Address - Fax:903-874-8829
Practice Address - Street 1:3229 W 7TH AVE
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-4817
Practice Address - Country:US
Practice Address - Phone:903-872-9910
Practice Address - Fax:903-874-8829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1499332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183236201Medicaid
TX018605801Medicaid
DF1159OtherRAILROAD MCR
00W808Medicare PIN
DF1159OtherRAILROAD MCR