Provider Demographics
NPI:1780654970
Name:PETERSON, BRIAN DREW (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DREW
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 1:25000 N. NORTERRA PARKWAY
Mailing Address - Street 2:BUILDING B
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085
Mailing Address - Country:US
Mailing Address - Phone:623-277-1000
Mailing Address - Fax:
Practice Address - Street 1:7287 E. EARLL DRIVE
Practice Address - Street 2:BUILDING D
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251
Practice Address - Country:US
Practice Address - Phone:480-840-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ172396Medicaid
AZD38809Medicare UPIN
AZ172396Medicaid