Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RG0300X | Geriatric Medicine | ME0068819 | FL |
Y | 207RH0002X | Hospice and Palliative Medicine | ME0068819 | FL |
NPI | 1265655757 |
---|---|
Provider Name | Dr. Laurence Milton Petty |
First Address | Plant City, FL 33567-3408 |
Second Address | Plant City, FL 33567-3408 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2007 |
Last Update Date | 03/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
255973100 | (05) | FL |
E91974 | (02) | FL |