Healthcare Provider Details

I. General information

NPI: 1770564718
Provider Name (Legal Business Name): BRETT M PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N LEWIS ST
ORANGE CA
92868-1538
US

IV. Provider business mailing address

200 N LEWIS ST
ORANGE CA
92868-1538
US

V. Phone/Fax

Practice location:
  • Phone: 888-988-2800
  • Fax:
Mailing address:
  • Phone: 888-988-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberA74745
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberA74745
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: