Provider Demographics
NPI:1861614711
Name:PETTYJOHN, CHARISSA JOY (MD)
Entity type:Individual
Prefix:
First Name:CHARISSA
Middle Name:JOY
Last Name:PETTYJOHN
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 1:19 PEVERELL ST
Mailing Address - Street 2:APT 3
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125
Mailing Address - Country:US
Mailing Address - Phone:857-212-3169
Mailing Address - Fax:
Practice Address - Street 1:750 WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111
Practice Address - Country:US
Practice Address - Phone:617-636-0265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225481207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative Medicine