Provider Demographics
NPI:1972671972
Name:PETERSON, THOMAS (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:PETERSON
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 1:17525 VENTURA BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-5109
Mailing Address - Country:US
Mailing Address - Phone:818-986-0200
Mailing Address - Fax:818-638-5762
Practice Address - Street 1:3628 E IMPERIAL HWY
Practice Address - Street 2:SUITE #300
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2609
Practice Address - Country:US
Practice Address - Phone:310-900-8490
Practice Address - Fax:310-635-0738
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26295174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A262950Medicaid
CAA26295Medicare ID - Type Unspecified