Provider Demographics
NPI:1366491029
Name:PETTY, STEPHEN MARRS (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MARRS
Last Name:PETTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27800 MEDICAL CENTER RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6410
Mailing Address - Country:US
Mailing Address - Phone:949-364-5315
Mailing Address - Fax:949-364-6515
Practice Address - Street 1:27800 MEDICAL CENTER RD
Practice Address - Street 2:SUITE 350
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6410
Practice Address - Country:US
Practice Address - Phone:949-364-5315
Practice Address - Fax:949-364-6515
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG392382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92059Medicare UPIN