Provider Demographics
NPI:1881635076
Name:PETERS, TIMOTHY D (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:PETERS
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 1:2235 MERCURY WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5473
Mailing Address - Country:US
Mailing Address - Phone:707-239-4426
Mailing Address - Fax:
Practice Address - Street 1:2235 MERCURY WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5473
Practice Address - Country:US
Practice Address - Phone:707-239-4426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY396462084P0804X
CAC1956272084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64105463Medicaid
KY64105463Medicaid
KYI04768Medicare UPIN