Healthcare Provider Details

I. General information

NPI: 1891729109
Provider Name (Legal Business Name): JOHN LOUIS PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 01/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9781 BLUE LARKSPUR LN STE 100
MONTEREY CA
93940-6509
US

IV. Provider business mailing address

6399 SAN IGNACIO AVE # 120
SAN JOSE CA
95119-1215
US

V. Phone/Fax

Practice location:
  • Phone: 831-333-9008
  • Fax: 831-333-9010
Mailing address:
  • Phone: 408-369-5600
  • Fax: 408-558-7949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG58431
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number1862071205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: