Provider Demographics
NPI:1952726242
Name:BRADLEY M. PETERSON, M.D., INC.
Entity Type:Organization
Organization Name:BRADLEY M. PETERSON, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:MORRIS
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-966-5863
Mailing Address - Street 1:3030 CHILDRENS WAY
Mailing Address - Street 2:#115
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4232
Mailing Address - Country:US
Mailing Address - Phone:858-966-5863
Mailing Address - Fax:858-279-8415
Practice Address - Street 1:3030 CHILDRENS WAY
Practice Address - Street 2:#115
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4232
Practice Address - Country:US
Practice Address - Phone:858-966-5863
Practice Address - Fax:858-279-8415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21961207LP3000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric AnesthesiologyGroup - Multi-Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA41436Medicare UPIN