Provider Demographics
NPI:1720280753
Name:PETTY, JARED B (DO)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:B
Last Name:PETTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75494-2604
Mailing Address - Country:US
Mailing Address - Phone:903-342-3355
Mailing Address - Fax:
Practice Address - Street 1:209 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-2604
Practice Address - Country:US
Practice Address - Phone:903-342-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7519207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7527715699005OtherTRICARE
TX8V3853OtherBCBS
TX75-2616977-042OtherTRICARE
TX206328102Medicaid
TX8DB900OtherBCBS
TXTIN PLUS 083OtherTRICARE
TX206328102Medicaid
TXTXB106083Medicare Oscar/Certification
TXP01005237Medicare Oscar/Certification