Healthcare Provider Details

I. General information

NPI: 1316943129
Provider Name (Legal Business Name): TODD W PETERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15785 LAGUNA CANYON RD STE 125
IRVINE CA
92618-3140
US

IV. Provider business mailing address

15785 LAGUNA CANYON RD STE 125
IRVINE CA
92618-3140
US

V. Phone/Fax

Practice location:
  • Phone: 949-383-4190
  • Fax: 949-383-4183
Mailing address:
  • Phone: 949-383-4190
  • Fax: 949-383-4183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number39517
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: