Provider Demographics
NPI:1356768790
Name:PETTEE, BRETT
Entity type:Individual
Prefix:MS
First Name:BRETT
Middle Name:
Last Name:PETTEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 CHANNELSIDE WALK WAY
Mailing Address - Street 2:#1130
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-6748
Mailing Address - Country:US
Mailing Address - Phone:617-922-4937
Mailing Address - Fax:
Practice Address - Street 1:1 DIAMOND HILL RD
Practice Address - Street 2:
Practice Address - City:BERKELEY HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07922-2104
Practice Address - Country:US
Practice Address - Phone:908-277-8625
Practice Address - Fax:908-608-2378
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA10042800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program