Provider Demographics
NPI:1730334079
Name:PETTY, RICHARD GEORGE (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:GEORGE
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 1:2430 TUCKER DR
Mailing Address - Street 2:BLDG A
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-4390
Mailing Address - Country:US
Mailing Address - Phone:770-554-8812
Mailing Address - Fax:
Practice Address - Street 1:2430 TUCKER DR
Practice Address - Street 2:BLDG A
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4390
Practice Address - Country:US
Practice Address - Phone:770-554-8812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052287L2084P0800X
PAAK000401L171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No171100000XOther Service ProvidersAcupuncturist