Provider Demographics
NPI:1861605420
Name:STEVEN H. PETERSON, M.D., INC.
Entity type:Organization
Organization Name:STEVEN H. PETERSON, M.D., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-532-6961
Mailing Address - Street 1:691 PAULINE CT
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5216
Mailing Address - Country:US
Mailing Address - Phone:209-532-6961
Mailing Address - Fax:209-532-0537
Practice Address - Street 1:691 PAULINE CT
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5216
Practice Address - Country:US
Practice Address - Phone:209-532-6961
Practice Address - Fax:209-532-0537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43320174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG43320OtherSTATE LICENSE NUMBER
CA00G43320Medicaid
CA00G43320Medicaid
CAA49311Medicare UPIN