Provider Demographics
NPI:1265599922
Name:PETERSON, MONTY ROE (MD)
Entity type:Individual
Prefix:
First Name:MONTY
Middle Name:ROE
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 1:6556 LONETREE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-6008
Mailing Address - Country:US
Mailing Address - Phone:916-781-9000
Mailing Address - Fax:
Practice Address - Street 1:6556 LONETREE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765
Practice Address - Country:US
Practice Address - Phone:916-781-9000
Practice Address - Fax:916-781-9020
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH96512Medicare UPIN