Provider Demographics
NPI:1033170121
Name:PETTI, THEODORE A (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:A
Last Name:PETTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 WEST GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:671 HOES LN
Practice Address - Street 2:UNIVERSITY BEHAVIORAL HEALTHCARE ROOM C-202
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-5627
Practice Address - Country:US
Practice Address - Phone:732-235-2129
Practice Address - Fax:732-235-2101
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA075870002084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0013382Medicaid
C29542Medicare UPIN
076391Medicare PIN