Provider Demographics
NPI:1043526569
Name:DALLAS PETERSON MD PLLC
Entity Type:Organization
Organization Name:DALLAS PETERSON MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CROWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-537-7011
Mailing Address - Street 1:1600 S WHITE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7106
Mailing Address - Country:US
Mailing Address - Phone:928-537-7011
Mailing Address - Fax:928-251-1063
Practice Address - Street 1:3401 LOCKWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5613
Practice Address - Country:US
Practice Address - Phone:928-368-2060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-21
Last Update Date:2010-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ23268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty