Provider Demographics
NPI:1033100664
Name:PETEET, JOHN RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RAYMOND
Last Name:PETEET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:75 FRANCIS STREET
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-278-0438
Mailing Address - Fax:617-632-6136
Practice Address - Street 1:1 BROOKLINE PLACE
Practice Address - Street 2:SUITE 502
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445
Practice Address - Country:US
Practice Address - Phone:617-278-0438
Practice Address - Fax:617-632-6136
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA369702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110037675Medicaid