Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CENTERVILLE RD BLDG E
WARWICK RI
02886-2778
US

IV. Provider business mailing address

250 CENTERVILLE RD BUILDING E
WARWICK RI
02886-4400
US

V. Phone/Fax

Practice location:
  • Phone: 401-921-5934
  • Fax: 401-921-5936
Mailing address:
  • Phone: 401-921-5934
  • Fax: 401-921-5936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number413
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: