Provider Demographics
NPI:1174734818
Name:PETTERWAY, GRETCHEN G (MD)
Entity type:Individual
Prefix:DR
First Name:GRETCHEN
Middle Name:G
Last Name:PETTERWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:
Other - Last Name:GILLYARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:9220 ELLERBE RD
Practice Address - Street 2:SUITE 700
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6739
Practice Address - Country:US
Practice Address - Phone:318-681-5282
Practice Address - Fax:318-681-5284
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.202577208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1079219Medicaid
LA4M138BC11Medicare PIN
LA4M138Medicare PIN
LA07921Medicaid
TX206831401Medicaid
LA1079219Medicaid