Provider Demographics
NPI:1194827865
Name:PETITT, KIMBERLY DENISE (DO)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DENISE
Last Name:PETITT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17516 US HIGHWAY 59 STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW CANEY
Mailing Address - State:TX
Mailing Address - Zip Code:77357-8718
Mailing Address - Country:US
Mailing Address - Phone:832-478-0200
Mailing Address - Fax:832-376-7509
Practice Address - Street 1:17516 US HIGHWAY 59 STE 110
Practice Address - Street 2:
Practice Address - City:NEW CANEY
Practice Address - State:TX
Practice Address - Zip Code:77357-8718
Practice Address - Country:US
Practice Address - Phone:832-478-0200
Practice Address - Fax:832-376-7509
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4912207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1194827865OtherTRICARE SOUTH
TX188605302Medicaid
TX8CJ367OtherBCBSTX
TX8CJ367OtherBCBSTX
TX188605302Medicaid
TX1194827865OtherTRICARE SOUTH
TXTXB103396Medicare PIN
TXCI5830Medicare PIN
TXP00432024Medicare PIN
TX8J8930Medicare PIN
TX1194827865Medicare PIN
TXP00843416Medicare PIN