Healthcare Provider Details

I. General information

NPI: 1861662884
Provider Name (Legal Business Name): MARY C GESSNER-PETERSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 ALPINE BLVD # 205
ALPINE CA
91901-2276
US

IV. Provider business mailing address

2710 ALPINE BLVD
ALPINE CA
91901-2276
US

V. Phone/Fax

Practice location:
  • Phone: 619-326-4445
  • Fax:
Mailing address:
  • Phone: 619-326-4445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberOS014103
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A1174
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: