Provider Demographics
NPI:1194778894
Name:PETTY, LEONORA K (MD)
Entity type:Individual
Prefix:
First Name:LEONORA
Middle Name:K
Last Name:PETTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-7719
Mailing Address - Country:US
Mailing Address - Phone:409-839-1000
Mailing Address - Fax:
Practice Address - Street 1:2750 S 8TH ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-7719
Practice Address - Country:US
Practice Address - Phone:409-839-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS205782084P0804X
PAMD035524L2084P0804X
TXP62422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I269052OtherMEDICARE
AL109062Medicaid
MS04428702Medicaid
PA1014016060001Medicaid
MS04428702Medicaid
A87983Medicare UPIN
AL109062Medicaid