Provider Demographics
NPI:1033281019
Name:PETERSON, KELSEY CARL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:CARL
Last Name:PETERSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:20462 KENWORTH CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-5446
Mailing Address - Country:US
Mailing Address - Phone:714-329-0179
Mailing Address - Fax:714-965-0311
Practice Address - Street 1:17742 BEACH BLVD
Practice Address - Street 2:245
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6818
Practice Address - Country:US
Practice Address - Phone:714-329-0179
Practice Address - Fax:714-965-0311
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG17592174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist