Provider Demographics
NPI:1821014374
Name:REGENTS OF UNIVERSITY OF CALIFORNIA
Entity Type:Organization
Organization Name:REGENTS OF UNIVERSITY OF CALIFORNIA
Other - Org Name:UCSF FRESNO MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSOCIATE DEAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-227-4810
Mailing Address - Street 1:2335 E KASHIAN LN STE 301
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93701-2234
Mailing Address - Country:US
Mailing Address - Phone:559-227-4810
Mailing Address - Fax:559-227-4167
Practice Address - Street 1:2335 E KASHIAN LN STE 301
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2234
Practice Address - Country:US
Practice Address - Phone:559-227-4810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF CA SAN FRANSICO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-15
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19509103G00000X
CAPSY20822103G00000X
CAG401330207QG0300X
CAG756682084N0400X
CA20A78882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1821014374OtherMEDICARE NPI
CA9151935Medicaid
CAZZZ52969YOtherBLUE OF CALIFORNIA
CAGPS001380Medicaid
CA2342434Medicaid
CACK5696OtherRAILROAD MEDICARE
CAGR0091021Medicaid
CA9151935Medicaid