Provider Demographics
NPI:1295795672
Name:PETERSEN, SANDRA ROSE (MD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:ROSE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 4TH AVE
Mailing Address - Street 2:SUITE 610
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-497-2430
Mailing Address - Fax:619-299-1723
Practice Address - Street 1:4060 4TH AVE
Practice Address - Street 2:SUITE 610
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-497-2430
Practice Address - Fax:619-299-1723
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG051961207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E91764Medicare UPIN
G51961Medicare ID - Type Unspecified