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General NPI Number Information
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NPI Number | 1316268386
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Entity Type | Organization
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Legal Business Name | CHARLES ROBERT PETTIT MD A MEDICAL CORPORATION
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Dates
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Enumeration Date | 06/14/2010
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Last Update Date | 08/14/2015
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Provider Practice Location Address
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Address Line | 175 CONCOURSE BLVD
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City | SANTA ROSA
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State | CA
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Zip | 95403-8217
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Country | US
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Telephone | 707-284-9200
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Fax | 707-284-9204
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Provider Business Mailing Address
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Address Line | 3906 HEATHFIELD PL
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City | SANTA ROSA
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State | CA
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Zip | 95404-7627
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Country | US
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Telephone | 707-843-3999
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Fax | 707-545-3999
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHARLES ROBERT PETTIT
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Credential | M.D.
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Telephone | 707-843-3999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YX0905X
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Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
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License Number |
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License Number State |
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