Healthcare Provider Details

I. General information

NPI: 1043248560
Provider Name (Legal Business Name): SOUTH DRIVE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 S DRIVE #15
MOUNTAIN VIEW CA
94040-4209
US

IV. Provider business mailing address

515 S DRIVE #15
MOUNTAIN VIEW CA
94040-4209
US

V. Phone/Fax

Practice location:
  • Phone: 650-961-9430
  • Fax:
Mailing address:
  • Phone: 650-961-9430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY4724
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG33788
License Number StateCA

VIII. Authorized Official

Name: MR. KENNETH S PETERS
Title or Position: PRESIDENT
Credential: MD
Phone: 650-961-9430