Healthcare Provider Details

I. General information

NPI: 1477843597
Provider Name (Legal Business Name): PETER DOUGLAS MCQUEEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 MONTECILLO RD
SAN RAFAEL CA
94903-3308
US

IV. Provider business mailing address

99 MONTICELLO RD MOB 2, 2ND FLOOR ORTHOPAEDICS
SAN RAFAEL CA
94903
US

V. Phone/Fax

Practice location:
  • Phone: 415-444-4430
  • Fax:
Mailing address:
  • Phone: 415-444-4430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036143839
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number141349
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: