Provider Demographics
NPI:1558448183
Name:PETTINATO, ANDREA A (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:A
Last Name:PETTINATO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-7181
Mailing Address - Fax:617-730-0184
Practice Address - Street 1:333 LONGWOOD AVE
Practice Address - Street 2:FLOOR 5
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5711
Practice Address - Country:US
Practice Address - Phone:617-355-5482
Practice Address - Fax:617-730-0185
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2146182080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2040514Medicaid
I04303Medicare UPIN
MA2040514Medicaid