Provider Demographics
NPI:1619406758
Name:PETERSON, DAYMON D (MD)
Entity Type:Individual
Prefix:
First Name:DAYMON
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 1:177 LEEK RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-0338
Mailing Address - Country:US
Mailing Address - Phone:209-303-1664
Mailing Address - Fax:
Practice Address - Street 1:201 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-3917
Practice Address - Country:US
Practice Address - Phone:662-432-4106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-11
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301119035207R00000X
CAA173077207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine