Provider Demographics
NPI:1083780837
Name:PETERSON, RAYMOND MACDONALD I (MD MPH)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:MACDONALD
Last Name:PETERSON
Suffix:I
Gender:M
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5663 GLENSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4332
Mailing Address - Country:US
Mailing Address - Phone:858-546-9094
Mailing Address - Fax:
Practice Address - Street 1:5663 GLENSTONE WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4332
Practice Address - Country:US
Practice Address - Phone:858-546-9094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC247952080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics