Provider Demographics
NPI:1033310677
Name:PETERSON, SOPHIE (MD)
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:PETERSON
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 1:6100 PAN AMERICAN FREEWAY
Mailing Address - Street 2:STE 450
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3460
Mailing Address - Country:US
Mailing Address - Phone:505-823-8787
Mailing Address - Fax:505-823-8788
Practice Address - Street 1:6100 PAN AMERICAN FREEWAY
Practice Address - Street 2:STE 450
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3460
Practice Address - Country:US
Practice Address - Phone:505-823-8787
Practice Address - Fax:505-823-8788
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117255207V00000X
NMMD20120713207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology