Healthcare Provider Details

I. General information

NPI: 1073571295
Provider Name (Legal Business Name): SAMUEL R PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 SAN MIGUEL DR STE 309
NEWPORT BEACH CA
92660-7829
US

IV. Provider business mailing address

600 CORPORATE DR STE 100
LADERA RANCH CA
92694-2107
US

V. Phone/Fax

Practice location:
  • Phone: 949-640-0434
  • Fax:
Mailing address:
  • Phone: 949-388-8022
  • Fax: 949-388-8033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number52631431205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberC148028
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: