Provider Demographics
NPI:1447331889
Name:PETTY, ELIZABETH MARIE (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
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 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:608-829-5485
Mailing Address - Fax:608-833-0999
Practice Address - Street 1:1500 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2274
Practice Address - Country:US
Practice Address - Phone:608-263-3301
Practice Address - Fax:608-265-7429
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28794-20207SG0201X, 208000000X
MI4301062920208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF76186Medicare UPIN
MI3031430Medicaid