Provider Demographics
NPI:1316019862
Name:PETERSEN, RICHARD WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WAYNE
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 S MARY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-3050
Mailing Address - Country:US
Mailing Address - Phone:408-733-0400
Mailing Address - Fax:408-733-4388
Practice Address - Street 1:1309 S MARY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-3050
Practice Address - Country:US
Practice Address - Phone:408-733-0400
Practice Address - Fax:408-733-4388
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 022120111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT39306Medicare UPIN