Healthcare Provider Details

I. General information

NPI: 1861614711
Provider Name (Legal Business Name): CHARISSA JOY PETTYJOHN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 WASHINGTON ST.
BOSTON MA
02111
US

IV. Provider business mailing address

19 PEVERELL ST APT 3
DORCHESTER MA
02125
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-0265
  • Fax:
Mailing address:
  • Phone: 857-212-3169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VH0002X
TaxonomyHospice and Palliative Medicine (Obstetrics & Gynecology) Physician
License Number225481
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: