Healthcare Provider Details

I. General information

NPI: 1497731095
Provider Name (Legal Business Name): JOHN K PETTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

PO BOX 344
WINSTON SALEM NC
27102-0344
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-2255
  • Fax: 336-716-6637
Mailing address:
  • Phone: 336-716-2255
  • Fax: 336-716-6637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number200501628
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number200501628
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number200501628
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: