Provider Demographics
NPI:1467495986
Name:PETERSEN, GLEN W (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:W
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:411 30TH ST
Mailing Address - Street 2:SUITE 314
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3312
Mailing Address - Country:US
Mailing Address - Phone:510-841-0689
Mailing Address - Fax:510-841-8119
Practice Address - Street 1:411 30TH ST
Practice Address - Street 2:SUITE 314
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3312
Practice Address - Country:US
Practice Address - Phone:510-465-6800
Practice Address - Fax:510-268-0634
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA26004207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A260040Medicaid
A24668Medicare UPIN
CA00A260040Medicaid