Healthcare Provider Details

I. General information

NPI: 1972671972
Provider Name (Legal Business Name): THOMAS PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 10/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3628 E IMPERIAL HWY SUITE #300
LYNWOOD CA
90262-2609
US

IV. Provider business mailing address

17525 VENTURA BLVD SUITE 203
ENCINO CA
91316-5109
US

V. Phone/Fax

Practice location:
  • Phone: 310-900-8490
  • Fax: 310-635-0738
Mailing address:
  • Phone: 818-986-0200
  • Fax: 818-638-5762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA26295
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: