Healthcare Provider Details

I. General information

NPI: 1972504280
Provider Name (Legal Business Name): STEPHEN JOSEPH PETTERUTI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 08/23/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 LAS OLAS WAY STE 214
FORT LAUDERDALE FL
33301-2883
US

IV. Provider business mailing address

333 LAS OLAS WAY STE 214
FORT LAUDERDALE FL
33301-2883
US

V. Phone/Fax

Practice location:
  • Phone: 401-580-4477
  • Fax: 833-818-9095
Mailing address:
  • Phone: 954-369-9079
  • Fax: 833-818-9095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22249
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: