Provider Demographics
NPI:1164662714
Name:PETERSON, ROY C (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:C
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:20322 OAKDALE LN
Mailing Address - Street 2:
Mailing Address - City:TEHACHAPI
Mailing Address - State:CA
Mailing Address - Zip Code:93561-7649
Mailing Address - Country:US
Mailing Address - Phone:661-972-2874
Mailing Address - Fax:661-823-8106
Practice Address - Street 1:115 WEST E STREET
Practice Address - Street 2:
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93581-1900
Practice Address - Country:US
Practice Address - Phone:661-972-2874
Practice Address - Fax:661-823-8106
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG036719207PE0004X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine