Healthcare Provider Details

I. General information

NPI: 1952726242
Provider Name (Legal Business Name): BRADLEY M. PETERSON, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2014
Last Update Date: 02/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 CHILDRENS WAY #115
SAN DIEGO CA
92123-4232
US

IV. Provider business mailing address

3030 CHILDRENS WAY #115
SAN DIEGO CA
92123-4232
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-5863
  • Fax: 858-279-8415
Mailing address:
  • Phone: 858-966-5863
  • Fax: 858-279-8415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberG21961
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberG21961
License Number StateCA

VIII. Authorized Official

Name: DR. BRADLEY MORRIS PETERSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 858-966-5863