Provider Demographics
NPI:1326265083
Name:DENNIS A PETERSEN D.O. INC
Entity Type:Organization
Organization Name:DENNIS A PETERSEN D.O. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:951-506-3112
Mailing Address - Street 1:27403 YNEZ RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591
Mailing Address - Country:US
Mailing Address - Phone:951-506-3112
Mailing Address - Fax:951-506-3116
Practice Address - Street 1:27403 YNEZ RD
Practice Address - Street 2:SUITE 103
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5603
Practice Address - Country:US
Practice Address - Phone:951-506-3112
Practice Address - Fax:951-506-3116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4978208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD76083Medicare UPIN