Provider Demographics
NPI:1952302143
Name:PETERSON, CHARLES SMITH (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:SMITH
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8630 E VIA DE VENTURA STE 201
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-3358
Mailing Address - Country:US
Mailing Address - Phone:480-558-3744
Mailing Address - Fax:480-558-3801
Practice Address - Street 1:3130 E BASELINE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7290
Practice Address - Country:US
Practice Address - Phone:480-558-3744
Practice Address - Fax:480-558-3801
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28027207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ102034Medicare PIN
AZH09839Medicare UPIN