Provider Demographics
NPI:1326089806
Name:PETALUMA VALLEY INTERNAL MEDICINE INC
Entity Type:Organization
Organization Name:PETALUMA VALLEY INTERNAL MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:STREETER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-765-1070
Mailing Address - Street 1:1310 COMMERCE ST #B
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-1469
Mailing Address - Country:US
Mailing Address - Phone:707-778-7862
Mailing Address - Fax:707-778-0969
Practice Address - Street 1:1250 BROADWAY
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-7500
Practice Address - Country:US
Practice Address - Phone:707-262-6267
Practice Address - Fax:707-734-7766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55098207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52861Medicare UPIN
CAZZZ03923ZMedicare PIN