Provider Demographics
NPI:1194862433
Name:PETERSON, TIMOTHY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
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 1:2540 N AVENIDA SORGO
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85749-8113
Mailing Address - Country:US
Mailing Address - Phone:520-760-8895
Mailing Address - Fax:
Practice Address - Street 1:3141 N 3RD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4351
Practice Address - Country:US
Practice Address - Phone:602-331-5174
Practice Address - Fax:602-745-7950
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15942207Q00000X
WI20764207Q00000X
MN22229207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine