Provider Demographics
NPI:1598787764
Name:PETERSON, DOUGLAS ALVIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:ALVIN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD
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 201
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93011-0201
Mailing Address - Country:US
Mailing Address - Phone:805-388-8330
Mailing Address - Fax:805-388-8030
Practice Address - Street 1:1901 OUTLET CENTER DR
Practice Address - Street 2:SUITE 220
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-0663
Practice Address - Country:US
Practice Address - Phone:805-388-8330
Practice Address - Fax:805-388-8030
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17831103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP56383Medicare UPIN
CAWCP17831BMedicare ID - Type Unspecified