Healthcare Provider Details

I. General information

NPI: 1609166545
Provider Name (Legal Business Name): RYAN C PETERSON MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 HILLOCK DR
LOS ANGELES CA
90068-1427
US

IV. Provider business mailing address

PO BOX 7001
TARZANA CA
91357-7001
US

V. Phone/Fax

Practice location:
  • Phone: 310-266-3774
  • Fax: 323-380-7420
Mailing address:
  • Phone: 818-888-7815
  • Fax: 818-715-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA103097
License Number StateCA

VIII. Authorized Official

Name: RYAN C PETERSON
Title or Position: DIRECT OWNER
Credential: MD
Phone: 310-266-3774