Provider Demographics
NPI:1336134758
Name:PETERSON, MIMI M (MD)
Entity Type:Individual
Prefix:DR
First Name:MIMI
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7507 E. TANQUE VERDE ROAD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715
Mailing Address - Country:US
Mailing Address - Phone:520-722-2585
Mailing Address - Fax:520-722-1097
Practice Address - Street 1:7507 E. TANQUE VERDE RROAD
Practice Address - Street 2:101
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715
Practice Address - Country:US
Practice Address - Phone:520-722-2585
Practice Address - Fax:520-722-1097
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ20854208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF34799Medicare UPIN