Provider Demographics
NPI:1376510313
Name:PETERSON, MILES ELLIS (PHD)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:ELLIS
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8283 GROVE AVE
Mailing Address - Street 2:#104
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-920-9906
Mailing Address - Fax:909-920-4151
Practice Address - Street 1:8283 GROVE AVE
Practice Address - Street 2:#104
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-920-9906
Practice Address - Fax:909-920-4151
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU1139237600000X
CAHA2555237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0011390Medicaid
ZZZ18056ZMedicare ID - Type Unspecified