Provider Demographics
NPI:1205880861
Name:PETTERSSON, L STAFFAN (MD)
Entity type:Individual
Prefix:
First Name:L
Middle Name:STAFFAN
Last Name:PETTERSSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LARS
Other - Middle Name:STAFFAN
Other - Last Name:PETTERSSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:13640 N PLAZA DEL RIO BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4846
Mailing Address - Country:US
Mailing Address - Phone:623-876-3800
Mailing Address - Fax:623-876-3809
Practice Address - Street 1:13640 N PLAZA DEL RIO BLVD
Practice Address - Street 2:STE 220
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4846
Practice Address - Country:US
Practice Address - Phone:623-876-3850
Practice Address - Fax:623-876-3809
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26390207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ424200Medicaid
AZZ77531Medicare PIN
AZ110196444Medicare PIN
AZ424200Medicaid
AZZ60102Medicare PIN