Provider Demographics
NPI:1083774897
Name:PETERSON, STEVEN H (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:H
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 1:691 PAULINE CT
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5216
Mailing Address - Country:US
Mailing Address - Phone:209-532-6961
Mailing Address - Fax:209-532-0537
Practice Address - Street 1:691 PAULINE CT
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5216
Practice Address - Country:US
Practice Address - Phone:209-532-6961
Practice Address - Fax:209-532-0537
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43320174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G43320Medicaid
CACQ974ZOtherSTAFF INDIV PTAN MEDICARE-TEMPLETON/TWIN CITIES COMM HOSP
CAZZZ12989ZMedicare ID - Type UnspecifiedMEDICARE
CA00G43320Medicaid