Provider Demographics
NPI:1982608907
Name:PETERSON, JULIE L (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4633 E CHANDLER BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0431
Mailing Address - Country:US
Mailing Address - Phone:480-776-0440
Mailing Address - Fax:480-776-0444
Practice Address - Street 1:4633 E CHANDLER BLVD
Practice Address - Street 2:STE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0431
Practice Address - Country:US
Practice Address - Phone:480-776-0440
Practice Address - Fax:480-776-0444
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26416208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ432550Medicaid