Healthcare Provider Details

I. General information

NPI: 1326183583
Provider Name (Legal Business Name): CHARLES ROBERT PETTIT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 ANDRIEUX ST STE 106
SONOMA CA
95476-6920
US

IV. Provider business mailing address

PO BOX 4489
CARMEL CA
93921-4489
US

V. Phone/Fax

Practice location:
  • Phone: 707-931-6485
  • Fax: 707-581-1766
Mailing address:
  • Phone: 707-931-6485
  • Fax: 707-581-1766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberA235594
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: