Provider Demographics
NPI:1528041886
Name:PETERSON, TIMOTHY D (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:108 SUTTON PLACE
Mailing Address - City:TAOS SKI VALLEY
Mailing Address - State:NM
Mailing Address - Zip Code:87525-0067
Mailing Address - Country:US
Mailing Address - Phone:575-766-8421
Mailing Address - Fax:575-776-8942
Practice Address - Street 1:108 SUTTON PLACE
Practice Address - Street 2:
Practice Address - City:TAOS SKI VALLEY
Practice Address - State:NM
Practice Address - Zip Code:87525-0067
Practice Address - Country:US
Practice Address - Phone:575-766-8421
Practice Address - Fax:575-776-8942
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2528207P00000X
NM81-285207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM33282Medicaid
NM1017580001Medicare NSC
E13820Medicare UPIN