Provider Demographics
NPI:1942250808
Name:PETERSEN, DAVID JAMES (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JAMES
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24191 PASEO DE VALENCIA
Mailing Address - Street 2:SUITE E
Mailing Address - City:LAGUNA WOODS
Mailing Address - State:CA
Mailing Address - Zip Code:92637-3167
Mailing Address - Country:US
Mailing Address - Phone:949-855-1177
Mailing Address - Fax:949-855-6939
Practice Address - Street 1:24191 PASEO DE VALENCIA
Practice Address - Street 2:SUITE E
Practice Address - City:LAGUNA WOODS
Practice Address - State:CA
Practice Address - Zip Code:92637-3167
Practice Address - Country:US
Practice Address - Phone:949-855-1177
Practice Address - Fax:949-855-6939
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4310213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADE7237OtherRAILROAD MEDI-CARE PIN
CA000E43100Medicare ID - Type Unspecified
CAW19818Medicare PIN
CAU86681Medicare UPIN