Provider Demographics
NPI:1326183583
Name:PETTIT, CHARLES ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROBERT
Last Name:PETTIT
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:PO BOX 4489
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93921-4489
Mailing Address - Country:US
Mailing Address - Phone:707-931-6485
Mailing Address - Fax:707-581-1766
Practice Address - Street 1:181 ANDRIEUX ST STE 106
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-6920
Practice Address - Country:US
Practice Address - Phone:707-931-6485
Practice Address - Fax:707-581-1766
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA235594207YX0905X
CAA23559207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty