Provider Demographics
NPI:1023504412
Name:PETERSON, CHRISTOPHER RUSSELL (IDEPENDENT DUTY CORP)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:RUSSELL
Last Name:PETERSON
Suffix:
Gender:M
Credentials:IDEPENDENT DUTY CORP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34101 FARENHOLT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-7000
Mailing Address - Country:US
Mailing Address - Phone:619-532-7968
Mailing Address - Fax:
Practice Address - Street 1:909 ASH RD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-8664
Practice Address - Country:US
Practice Address - Phone:818-404-4527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman