Provider Demographics
NPI:1871680314
Name:PETERS, WARREN R (MD)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:R
Last Name:PETERS
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 1:24785 STEWART ST RM 111
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-0001
Mailing Address - Country:US
Mailing Address - Phone:909-558-4594
Mailing Address - Fax:909-558-4838
Practice Address - Street 1:24785 STEWART ST RM 111
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-0001
Practice Address - Country:US
Practice Address - Phone:909-558-4594
Practice Address - Fax:909-558-4838
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68292174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB07349Medicare UPIN