1184625394 NPI number — DR. DOUGLAS R PETTY D.C.

Table of content: DR. DOUGLAS R PETTY D.C. (NPI 1184625394)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184625394 NPI number — DR. DOUGLAS R PETTY D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTY
Provider First Name:
DOUGLAS
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184625394
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29021 UPPER BEAR CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERGREEN
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80439-7704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-670-8842
Provider Business Mailing Address Fax Number:
303-670-7742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29021 UPPER BEAR CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERGREEN
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80439-7704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-670-8842
Provider Business Practice Location Address Fax Number:
303-670-7742
Provider Enumeration Date:
08/10/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3299 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 653765 . This is a "UNITED HEALTHCARE ID" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".