Provider Demographics
NPI:1861662884
Name:GESSNER-PETERSON, MARY C (DO)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
Last Name:GESSNER-PETERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 ALPINE BLVD
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-2276
Mailing Address - Country:US
Mailing Address - Phone:619-326-4445
Mailing Address - Fax:
Practice Address - Street 1:2710 ALPINE BLVD # 205
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-2276
Practice Address - Country:US
Practice Address - Phone:619-326-4445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-05
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A1174207R00000X
PAOS014103207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA825521721OtherURGENT CARE TAX ID