Provider Demographics
NPI:1851435838
Name:PETERSEN, MAX G (DC)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:G
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1373 S BASCOM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4507
Mailing Address - Country:US
Mailing Address - Phone:408-288-8120
Mailing Address - Fax:408-288-8122
Practice Address - Street 1:1373 S BASCOM AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4507
Practice Address - Country:US
Practice Address - Phone:408-288-8120
Practice Address - Fax:408-288-8122
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29375111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor