Provider Demographics
NPI:1750453759
Name:PETERSON, ALEXANDER OLAF JR (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:OLAF
Last Name:PETERSON
Suffix:JR
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 1:6185 AGEE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122
Mailing Address - Country:US
Mailing Address - Phone:858-552-0402
Mailing Address - Fax:
Practice Address - Street 1:6185 AGEE ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122
Practice Address - Country:US
Practice Address - Phone:858-552-0402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA044622207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA044622Medicare ID - Type Unspecified
D71775Medicare UPIN