Provider Demographics
NPI:1437234499
Name:PETERSON, CHARLES JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOHN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5700 E PIMA STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-5601
Mailing Address - Country:US
Mailing Address - Phone:520-382-2819
Mailing Address - Fax:520-382-2832
Practice Address - Street 1:5301 E GRANT ROAD
Practice Address - Street 2:TUCSON MEDICAL CENTER EMERGENCY DEPARTMENT
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2805
Practice Address - Country:US
Practice Address - Phone:520-324-1922
Practice Address - Fax:520-324-1088
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ21030207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ150384OtherAHCCCS
AZ15038402Medicaid
F69477Medicare UPIN
AZ150384OtherAHCCCS