Provider Demographics
NPI:1760496202
Name:PETERSON, RICHARD BERTRAM (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BERTRAM
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 1:1661 SOQUEL DR
Mailing Address - Street 2:BUILDING G
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1709
Mailing Address - Country:US
Mailing Address - Phone:831-476-1542
Mailing Address - Fax:831-464-8977
Practice Address - Street 1:1661 SOQUEL DR
Practice Address - Street 2:BUILDING G
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1709
Practice Address - Country:US
Practice Address - Phone:831-476-1542
Practice Address - Fax:831-464-8977
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG283412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G283410Medicaid
CA00G283410Medicaid
P00140552Medicare PIN
00G283411Medicare PIN
E72068Medicare UPIN
00G283412Medicare PIN