Provider Demographics
NPI:1972504280
Name:PETTERUTI, STEPHEN (DO)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:PETTERUTI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 CENTERVILLE RD
Mailing Address - Street 2:BUILDING E
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4400
Mailing Address - Country:US
Mailing Address - Phone:401-921-5934
Mailing Address - Fax:401-921-5936
Practice Address - Street 1:250 CENTERVILLE RD
Practice Address - Street 2:BLDG E
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2778
Practice Address - Country:US
Practice Address - Phone:401-921-5934
Practice Address - Fax:401-921-5936
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI413207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI23631-3OtherBLUE CROSS BLUE SHIELD
RI0101123OtherUNITED HEALTH
RI203583OtherBCBS CHIP
RI2654722OtherAETNA
RI9003104Medicaid
RI0101123OtherUNITED HEALTH
RI203583OtherBCBS CHIP