Provider Demographics
NPI:1861452195
Name:PETTY, DAMON H (MD)
Entity type:Individual
Prefix:
First Name:DAMON
Middle Name:H
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:PO BOX 306556
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6556
Mailing Address - Country:US
Mailing Address - Phone:865-243-8153
Mailing Address - Fax:
Practice Address - Street 1:1035 S HARTMANN DR STE 300
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-4064
Practice Address - Country:US
Practice Address - Phone:615-321-0200
Practice Address - Fax:615-443-5488
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36400207XX0005X
TNMD36400207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3877034Medicaid
TN5684990001Medicare NSC
TN3877034Medicaid
TNH47569Medicare UPIN