Provider Demographics
NPI:1093873978
Name:PETERSEN, TERRY P (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:P
Last Name:PETERSEN
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 1:9890 COUNTY FARM RD STE 1
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3505
Mailing Address - Country:US
Mailing Address - Phone:951-358-4850
Mailing Address - Fax:
Practice Address - Street 1:9890 COUNTY FARM RD STE 1
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3505
Practice Address - Country:US
Practice Address - Phone:951-358-4850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG778472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG25652Medicare UPIN