Provider Demographics
NPI:1063473023
Name:PETERSON, DREW ALAN (MD)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:ALAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7485 MISSION VALLEY RD
Mailing Address - Street 2:SUITE 104 A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4422
Mailing Address - Country:US
Mailing Address - Phone:619-291-8930
Mailing Address - Fax:619-291-8491
Practice Address - Street 1:7485 MISSION VALLEY RD
Practice Address - Street 2:SUITE 104 A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4422
Practice Address - Country:US
Practice Address - Phone:619-291-8930
Practice Address - Fax:619-291-8491
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65990207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G28589Medicare UPIN
W1762Medicare ID - Type Unspecified