Healthcare Provider Details

I. General information

NPI: 1487879987
Provider Name (Legal Business Name): PETER C. JEPPSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 03/29/2025
Certification Date: 03/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4344 E PRESIDIO ST
MESA AZ
85215-1143
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 480-834-5111
  • Fax: 480-834-5222
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberMD2013-0172
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: