Provider Demographics
NPI:1649461211
Name:PETTY, JOSEPH LEE (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:LEE
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 1:523 S FANNIN AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8204
Mailing Address - Country:US
Mailing Address - Phone:903-535-9041
Mailing Address - Fax:903-747-8163
Practice Address - Street 1:928 N GLENWOOD BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5055
Practice Address - Country:US
Practice Address - Phone:903-535-9041
Practice Address - Fax:903-533-0726
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6579207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX215374402Medicaid
TXTXB102462OtherMEDICARE GROUP PTAN
TX295206101OtherMEDICAID GROUP NUMBER
TXTXB146789OtherMEDICARE PTAN