Provider Demographics
NPI:1841359171
Name:PETERSON, BOBBY DEAN (MD)
Entity type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:DEAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2390 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:ESCALON
Mailing Address - State:CA
Mailing Address - Zip Code:95320-2078
Mailing Address - Country:US
Mailing Address - Phone:209-838-6015
Mailing Address - Fax:209-838-0750
Practice Address - Street 1:2390 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:ESCALON
Practice Address - State:CA
Practice Address - Zip Code:95320-2078
Practice Address - Country:US
Practice Address - Phone:209-838-6015
Practice Address - Fax:209-838-0750
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66903207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF21959Medicare UPIN
CA00G669030Medicare PIN