Healthcare Provider Details

I. General information

NPI: 1356332720
Provider Name (Legal Business Name): CHARLES JUSTIN PETIT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 08/25/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17355 LOWER BOONES FERRY RD #100A
LAKE OSWEGO OR
97035-2839
US

IV. Provider business mailing address

17355 LOWER BOONES FERRY RD #100A
LAKE OSWEGO OR
97035-2839
US

V. Phone/Fax

Practice location:
  • Phone: 503-224-8399
  • Fax: 503-224-5661
Mailing address:
  • Phone: 503-224-8399
  • Fax: 503-224-5661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD29397
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD29397
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: