Provider Demographics
NPI:1356332720
Name:PETIT, CHARLES JUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JUSTIN
Last Name:PETIT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1515 NW 18TH AVE
Mailing Address - Street 2:#300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2516
Mailing Address - Country:US
Mailing Address - Phone:503-224-8399
Mailing Address - Fax:503-224-5661
Practice Address - Street 1:1515 NW 18TH AVE
Practice Address - Street 2:#300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2516
Practice Address - Country:US
Practice Address - Phone:503-224-8399
Practice Address - Fax:503-224-5661
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO46345207X00000X
ORMD29397207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO301556Medicare PIN