Healthcare Provider Details

I. General information

NPI: 1548465750
Provider Name (Legal Business Name): CHARLES S PETERSON MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 N SCOTTSDALE RD SUITE 101
SCOTTSDALE AZ
85250-7075
US

IV. Provider business mailing address

PO BOX 2507
MESA AZ
85214-2507
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: DR. CHARLES S PETERSON
Title or Position: OWNER PRESIDENT
Credential: MD
Phone: 480-558-3744