Provider Demographics
NPI:1851311104
Name:PETERSON, RALPH L (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:L
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 1:10520 MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-5248
Mailing Address - Country:US
Mailing Address - Phone:510-562-7467
Mailing Address - Fax:510-635-9025
Practice Address - Street 1:10520 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-5248
Practice Address - Country:US
Practice Address - Phone:510-562-7467
Practice Address - Fax:510-635-9025
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49099207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G490990Medicaid
CA00G490990Medicaid
CAA51258Medicare UPIN