Provider Demographics
NPI:1275674517
Name:DESERT VISTA ANESTHESIOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:DESERT VISTA ANESTHESIOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:PERCY
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-796-4595
Mailing Address - Street 1:225 S LAKE AVE
Mailing Address - Street 2:535
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3005
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:626-795-8247
Practice Address - Street 1:15248 11TH ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3704
Practice Address - Country:US
Practice Address - Phone:760-245-8691
Practice Address - Fax:760-843-6050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ50059YOtherBLUE SHIELD
CAGR0105710Medicaid
CAZZZ50059YOtherBLUE SHIELD