Provider Demographics
NPI:1679578132
Name:PETTY, MICHAEL TRAVIS (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TRAVIS
Last Name:PETTY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10826 KINGSTON PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-3059
Mailing Address - Country:US
Mailing Address - Phone:865-675-5050
Mailing Address - Fax:865-671-1321
Practice Address - Street 1:10826 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-3059
Practice Address - Country:US
Practice Address - Phone:865-675-5050
Practice Address - Fax:865-671-1321
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2013-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC511111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1811205Medicaid
TN1811205Medicaid
TN3673809Medicare ID - Type UnspecifiedMEDICARE NUMBER