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1194778894

NPI Code Detail

MEDICARE: LEONORA K PETTY MD

MEDICARE: LEONORA K PETTY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	20578	MS
2	2084P0804X	Child & Adolescent Psychiatry Physician	MD035524L	PA
3	2084P0800X	Psychiatry Physician	P6242	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	302I269052	OTHER	MS	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194778894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEONORA K PETTY MD

Provider Business Mailing Address
First Line	:	2750 S 8TH ST
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77701-7719
Country	:	US
Telephone Number	:	409-839-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2750 S 8TH ST
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77701-7719
Country	:	US
Telephone Number	:	409-839-1000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	04/20/2022

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Directions to “ LEONORA K PETTY MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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