Provider Demographics
NPI:1275513426
Name:PETTWAY, DARNELL D (MD)
Entity type:Individual
Prefix:
First Name:DARNELL
Middle Name:D
Last Name:PETTWAY
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:PO BOX 200993
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77216-0993
Mailing Address - Country:US
Mailing Address - Phone:281-784-1111
Mailing Address - Fax:281-784-1555
Practice Address - Street 1:4000 SPENCER HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-1202
Practice Address - Country:US
Practice Address - Phone:713-359-2000
Practice Address - Fax:713-359-1004
Is Sole Proprietor?:No
Enumeration Date:2006-01-21
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4644207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154206002Medicaid
TX8G4110OtherBC/BS PROVIDER NUMBER
TX154206001Medicaid
TX8G8842Medicare PIN
TX8L24794Medicare PIN
TXH71841Medicare UPIN
TX8A0278Medicare PIN
TX154206001Medicaid