Healthcare Provider Details

I. General information

NPI: 1174739288
Provider Name (Legal Business Name): DOUGLAS CHARLES PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9260 LAGUNA SPRINGS DR SUITE E2-308
ELK GROVE CA
95758-7947
US

IV. Provider business mailing address

PO BOX 588500 SUITE E2-308
ELK GROVE CA
95758-8500
US

V. Phone/Fax

Practice location:
  • Phone: 916-691-9574
  • Fax:
Mailing address:
  • Phone: 916-691-9574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG42408
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG42408
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License NumberG42408
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: