Provider Demographics
NPI:1073818555
Name:TIMOTHY D PETERSON, MD PC
Entity Type:Organization
Organization Name:TIMOTHY D PETERSON, MD PC
Other - Org Name:MOGUL MEDICAL URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-776-8421
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:TAOS SKI VALLEY
Mailing Address - State:NM
Mailing Address - Zip Code:87525-0067
Mailing Address - Country:US
Mailing Address - Phone:575-776-8421
Mailing Address - Fax:575-776-8942
Practice Address - Street 1:108 SUTTON PLACE
Practice Address - Street 2:
Practice Address - City:TAOS SKI VALLEY
Practice Address - State:NM
Practice Address - Zip Code:87525
Practice Address - Country:US
Practice Address - Phone:575-776-8421
Practice Address - Fax:575-776-8942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-14
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81-285207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1017580001Medicare NSC