Provider Demographics
NPI:1275565624
Name:PETERS, KENNETH SCOTT (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:SCOTT
Last Name:PETERS
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 1:515 SOUTH DRIVE
Mailing Address - Street 2:#15
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040
Mailing Address - Country:US
Mailing Address - Phone:650-961-9430
Mailing Address - Fax:
Practice Address - Street 1:515 SOUTH DRIVE
Practice Address - Street 2:#15
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040
Practice Address - Country:US
Practice Address - Phone:650-961-9430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A45679Medicare UPIN
CAZZZ85022ZMedicare ID - Type Unspecified