Provider Demographics
NPI:1255430716
Name:PETERSEN, PAMELA O (MD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:O
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:PAMELA
Other - Middle Name:JANE
Other - Last Name:OLDHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2330 W COVELL BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-5658
Mailing Address - Country:US
Mailing Address - Phone:530-756-2364
Mailing Address - Fax:
Practice Address - Street 1:2330 W COVELL BLVD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-5658
Practice Address - Country:US
Practice Address - Phone:530-756-2364
Practice Address - Fax:530-756-5817
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49282208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A492820Medicaid
CA00A492820OtherBLUE SHIELD