Provider Demographics
NPI:1114232204
Name:B D PETERSON MD INC
Entity Type:Organization
Organization Name:B D PETERSON MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-838-6015
Mailing Address - Street 1:2390 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:ESCALON
Mailing Address - State:CA
Mailing Address - Zip Code:95320-2078
Mailing Address - Country:US
Mailing Address - Phone:209-838-6015
Mailing Address - Fax:209-838-0750
Practice Address - Street 1:2390 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:ESCALON
Practice Address - State:CA
Practice Address - Zip Code:95320-2078
Practice Address - Country:US
Practice Address - Phone:209-838-6015
Practice Address - Fax:209-838-0750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66903207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF21959Medicare UPIN
CA00G669030Medicare PIN