Healthcare Provider Details

I. General information

NPI: 1407776701
Provider Name (Legal Business Name): VICTORIA PETTY
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: VICTORIA BLOSDALE

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 CIRCLE RD
PASADENA MD
21122-6001
US

IV. Provider business mailing address

79 CIRCLE RD
PASADENA MD
21122-6001
US

V. Phone/Fax

Practice location:
  • Phone: 765-517-3401
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberR260276
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: