Healthcare Provider Details

I. General information

NPI: 1104138106
Provider Name (Legal Business Name): JEAN CLAUDE PETIT ME D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 MILL RD
FAIRHAVEN MA
02719-5208
US

IV. Provider business mailing address

200 MILL RD STE 180
FAIRHAVEN MA
02719-5255
US

V. Phone/Fax

Practice location:
  • Phone: 508-973-2204
  • Fax: 508-973-2640
Mailing address:
  • Phone: 508-973-2000
  • Fax: 508-973-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number284338
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: