Provider Demographics
NPI:1508932906
Name:PETERSEN, DAVID JOHN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:68 708 AVENIDA DIOSA
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234
Mailing Address - Country:US
Mailing Address - Phone:818-781-7097
Mailing Address - Fax:818-904-0531
Practice Address - Street 1:14600 SHERMAN WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405
Practice Address - Country:US
Practice Address - Phone:818-781-7097
Practice Address - Fax:818-904-0531
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG60655208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
E25300Medicare UPIN