Provider Demographics
NPI:1811941198
Name:ANDERSON, PETER G (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:ANDERSON
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:PO BOX 20140
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92728-0140
Mailing Address - Country:US
Mailing Address - Phone:562-809-3572
Mailing Address - Fax:
Practice Address - Street 1:17100 EUCLID
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708
Practice Address - Country:US
Practice Address - Phone:714-966-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25988207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A259880Medicaid
CAAW553YMedicare PIN
CAWA25988AMedicare PIN
CAWA25988EMedicare PIN
CAAW553ZMedicare PIN
CAE50254Medicare UPIN
CAHA25988Medicare PIN
CAAW553XMedicare PIN