Provider Demographics
NPI:1154438315
Name:PETTY, GRANT DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:DOUGLAS
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:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25712-0910
Mailing Address - Country:US
Mailing Address - Phone:304-522-1550
Mailing Address - Fax:304-522-0704
Practice Address - Street 1:3448 US ROUTE 60
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2906
Practice Address - Country:US
Practice Address - Phone:304-522-1550
Practice Address - Fax:304-522-0704
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350892262085R0202X
GA0526172085R0202X
WV226822085R0202X
KY408412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7389831OtherAETNA
OH2732556Medicaid
KY7100014760Medicaid
WVP00413759OtherRR MEDICARE
OH000000221879OtherUNISON
WV3810008705Medicaid
KY50017454OtherPASSPORT
WV001962777OtherMTN ST BCBS
WV550493376 00OtherWV WORKER'S COMPENSATION
WV4205971Medicare PIN
KY50017454OtherPASSPORT
WVP00413759OtherRR MEDICARE
WV550493376 00OtherWV WORKER'S COMPENSATION