Healthcare Provider Details

I. General information

NPI: 1821014374
Provider Name (Legal Business Name): REGENTS OF UNIVERSITY OF CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2335 E KASHIAN LN STE 301
FRESNO CA
93701-2234
US

IV. Provider business mailing address

2335 E KASHIAN LN STE 301
FRESNO CA
93701-2234
US

V. Phone/Fax

Practice location:
  • Phone: 559-227-4810
  • Fax:
Mailing address:
  • Phone: 559-227-4810
  • Fax: 559-227-4167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY19509
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY20822
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberG401330
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A7888
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberG75668
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL PETERSON
Title or Position: ASSOCIATE DEAN
Credential: M..D.
Phone: 559-227-4810