Individual
DR. WENDELL E PETTY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3422 S 15TH E, IDAHO FALLS, ID 83404-8262
(208) 529-9292
(208) 525-6013
Mailing address
3422 S 15TH E, IDAHO FALLS, ID 83404-8262
(208) 529-9292
(208) 525-6013
Taxonomy
Speciality
Code
Description
License number
State
207K00000X
Allergy & Immunology Physician
Primary
MD-2580
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010004631
BLUE SHIELD
ID
05
—
002516900
—
ID
01
—
030000684
RAILROAD MEDICARE
ID
01
—
76891
BLUE CROSS
ID
Enumeration date
03/30/2006
Last updated
06/21/2019
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