Provider Demographics
NPI:1942292321
Name:PETERSEN, LARRY SCOTT (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:SCOTT
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 WINHAM ST
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-3314
Mailing Address - Country:US
Mailing Address - Phone:831-771-0244
Mailing Address - Fax:831-771-0243
Practice Address - Street 1:31 WINHAM ST
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-3314
Practice Address - Country:US
Practice Address - Phone:831-771-0244
Practice Address - Fax:831-771-0243
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE92839Medicare UPIN
CA020A57330Medicare PIN