Provider Demographics
NPI:1295735959
Name:PETTY, CORWIN D (MD)
Entity type:Individual
Prefix:DR
First Name:CORWIN
Middle Name:D
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 1:3201 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
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-2717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142693001Medicaid
AR5C680OtherBLUE CROSS BLUE SHIELD
5L696OtherBLUE CROSS BLUE SHIELD
5L696OtherBLUE CROSS BLUE SHIELD
AR142693001Medicaid