Individual
KEITH PETTIBON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
815 PENNSYLVANIA AVE, FORT WORTH, TX 76104
(817) 321-0404
Mailing address
816 W CANNON ST, FORT WORTH, TX 76104-3146
(817) 321-0404
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
R1614
TX
2085R0204X
Vascular & Interventional Radiology Physician
R1614
TX
Other
Enumeration date
05/07/2011
Last updated
06/13/2024
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