Provider Demographics
NPI:1912140351
Name:PETERSON, KENNETH BRIAN (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BRIAN
Last Name:PETERSON
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 1:8757 E BELL RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1322
Mailing Address - Country:US
Mailing Address - Phone:480-860-5500
Mailing Address - Fax:480-860-5511
Practice Address - Street 1:8757 E BELL RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1322
Practice Address - Country:US
Practice Address - Phone:480-860-5500
Practice Address - Fax:480-860-5511
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-15
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14333207R00000X
NH12173207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine