Provider Demographics
NPI:1750536611
Name:DENA PETERSEN, M.D. P.C
Entity type:Organization
Organization Name:DENA PETERSEN, M.D. P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENA
Authorized Official - Middle Name:E
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-293-1415
Mailing Address - Street 1:4574 N 1ST AVE STE 180
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-5699
Mailing Address - Country:US
Mailing Address - Phone:520-293-1415
Mailing Address - Fax:520-293-1434
Practice Address - Street 1:4574 N 1ST AVE STE 180
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-5699
Practice Address - Country:US
Practice Address - Phone:520-293-1415
Practice Address - Fax:520-293-1434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
10296OtherPREPCARE
AZAZ0817530OtherBLUE CROSS
AZZ20625OtherMEDICARE ID
0100823OtherUHC
9778467OtherCIGNA
AZAZ0817530OtherBLUE CROSS