Provider Demographics
NPI:1093868663
Name:PETERSON, BRADLEY S (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
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 1:2612 EL CAMINITO
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-2963
Mailing Address - Country:US
Mailing Address - Phone:914-582-1905
Mailing Address - Fax:
Practice Address - Street 1:2612 EL CAMINITO
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-2963
Practice Address - Country:US
Practice Address - Phone:914-582-1905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2218932084P0800X, 273R00000X
CAG1307372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No273R00000XHospital UnitsPsychiatric Unit