Healthcare Provider Details

I. General information

NPI: 1316268386
Provider Name (Legal Business Name): CHARLES ROBERT PETTIT MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 CONCOURSE BLVD
SANTA ROSA CA
95403-8217
US

IV. Provider business mailing address

3906 HEATHFIELD PL
SANTA ROSA CA
95404-7627
US

V. Phone/Fax

Practice location:
  • Phone: 707-284-9200
  • Fax: 707-284-9204
Mailing address:
  • Phone: 707-843-3999
  • Fax: 707-545-3999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES ROBERT PETTIT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 707-843-3999