Healthcare Provider Details

I. General information

NPI: 1952302143
Provider Name (Legal Business Name): CHARLES SMITH PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 E BASELINE RD SUITE 101
MESA AZ
85204-7290
US

IV. Provider business mailing address

8630 E VIA DE VENTURA STE 201
SCOTTSDALE AZ
85258-3358
US

V. Phone/Fax

Practice location:
  • Phone: 480-558-3744
  • Fax: 480-558-3801
Mailing address:
  • Phone: 480-558-3744
  • Fax: 480-558-3801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number28027
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: