Provider Demographics
NPI:1073663886
Name:PIERRE, PETERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:PETERSON
Middle Name:
Last Name:PIERRE
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 1:77 E. ROLLING OAKS DRIVE, SUITE 207
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361
Mailing Address - Country:US
Mailing Address - Phone:805-496-9190
Mailing Address - Fax:805-496-9185
Practice Address - Street 1:77 E. ROLLING OAKS DRIVE, SUITE 207
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361
Practice Address - Country:US
Practice Address - Phone:805-496-9190
Practice Address - Fax:805-496-9185
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66363174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH30926Medicare UPIN