Healthcare Provider Details

I. General information

NPI: 1699902759
Provider Name (Legal Business Name): MICHAEL ALEX PETERSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ALEX PETERSON PH.D.

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 LEIMERT BLVD SUITE 403
OAKLAND CA
94602-1865
US

IV. Provider business mailing address

1425 LEIMERT BLVD SUITE 403
OAKLAND CA
94602-1865
US

V. Phone/Fax

Practice location:
  • Phone: 510-531-0500
  • Fax: 510-336-0902
Mailing address:
  • Phone: 510-531-0500
  • Fax: 510-336-0902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number18593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: