Provider Demographics
NPI:1184625394
Name:PETTY, DOUGLAS R (DC)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:R
Last Name:PETTY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29021 UPPER BEAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7704
Mailing Address - Country:US
Mailing Address - Phone:303-670-8842
Mailing Address - Fax:303-670-7742
Practice Address - Street 1:29021 UPPER BEAR CREEK RD
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7704
Practice Address - Country:US
Practice Address - Phone:303-670-8842
Practice Address - Fax:303-670-7742
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3299111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO653765OtherUNITED HEALTHCARE ID
CO653765OtherUNITED HEALTHCARE ID