Healthcare Provider Details

I. General information

NPI: 1245214576
Provider Name (Legal Business Name): RICHARD ALLAN PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 LAS TABLAS RD SUITE 13
TEMPLETON CA
93465-9729
US

IV. Provider business mailing address

1050 LAS TABLAS RD SUITE 13
TEMPLETON CA
93465-9729
US

V. Phone/Fax

Practice location:
  • Phone: 805-434-1435
  • Fax: 805-434-3747
Mailing address:
  • Phone: 805-434-1435
  • Fax: 805-434-3747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG34095
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: