Provider Demographics
NPI:1073571295
Name:PETERSON, SAMUEL R (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
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 1:600 CORPORATE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-2107
Mailing Address - Country:US
Mailing Address - Phone:949-388-8022
Mailing Address - Fax:949-388-8033
Practice Address - Street 1:360 SAN MIGUEL DR STE 309
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7829
Practice Address - Country:US
Practice Address - Phone:949-640-0434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT52631431205207N00000X
CAC148028207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107017630101OtherIHC HEALTHPLANS
UTQM0000066345OtherALTIUS
UTP00066498OtherPALMETTO GBA
UT03.00174OtherUNITED HEALTHCARE
UT72756OtherPEHP
UT796725OtherDMBA
UT870281028000Medicaid
UTH81969Medicare UPIN