Healthcare Provider Details

I. General information

NPI: 1609839083
Provider Name (Legal Business Name): KENNETH G PETTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 ESPLANADE
CHICO CA
95926-3315
US

IV. Provider business mailing address

1720 ESPLANADE
CHICO CA
95926-3315
US

V. Phone/Fax

Practice location:
  • Phone: 530-898-0500
  • Fax: 530-898-9647
Mailing address:
  • Phone: 530-898-0504
  • Fax: 530-898-9647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberRHL144948
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: