Provider Demographics
NPI:1376545863
Name:PETERSON, JAMES ALLEN KRAFT (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ALLEN KRAFT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 PALOMINO LANE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4894
Mailing Address - Country:US
Mailing Address - Phone:702-759-8600
Mailing Address - Fax:702-384-1815
Practice Address - Street 1:145 OAK MEADOW RD
Practice Address - Street 2:
Practice Address - City:SIERRA MADRE
Practice Address - State:CA
Practice Address - Zip Code:91024-2661
Practice Address - Country:US
Practice Address - Phone:415-793-3269
Practice Address - Fax:702-384-1815
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A87152085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1376545863Medicaid
CA1376545863Medicaid
CAP01361869OtherRR MEDICARE DRS
CAP01361871OtherRR MEDICARE DR
CA1376545863Medicaid
CAP01361869OtherRR MEDICARE DRS
CACA120184Medicare PIN
CACB213416Medicare PIN
CACB214019Medicare PIN
CACB213415Medicare PIN
CACA120186Medicare PIN