Provider Demographics
NPI:1275980385
Name:PETETIT, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:PETETIT
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 1:33 LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-1048
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:
Practice Address - Street 1:400 FRANK W BURR BLVD # 6
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-6839
Practice Address - Country:US
Practice Address - Phone:201-304-7552
Practice Address - Fax:201-299-6631
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3054532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry