Individual
WILLIAM C PETTY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2200 RANDALLIA DR, FORT WAYNE, IN 46805-4638
(260) 373-4000
Mailing address
3707 NEW VISION DR, FORT WAYNE, IN 46845-1702
(260) 471-9466
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
01038794
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000092611
ANTHEM
IN
01
—
1696
PHP
IN
05
—
2100621
—
OH
05
—
4074933100
—
MI
Enumeration date
05/17/2006
Last updated
07/08/2007
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