Provider Demographics
NPI:1891729109
Name:PETERSON, JOHN LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LOUIS
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6399 SAN IGNACIO AVE # 120
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1215
Mailing Address - Country:US
Mailing Address - Phone:408-369-5600
Mailing Address - Fax:408-558-7949
Practice Address - Street 1:9781 BLUE LARKSPUR LN STE 100
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-6509
Practice Address - Country:US
Practice Address - Phone:831-333-9008
Practice Address - Fax:831-333-9010
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58431207N00000X
UT1862071205207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA93510Medicare UPIN
UT000059091Medicare PIN
000063466Medicare PIN