Healthcare Provider Details

I. General information

NPI: 1013939578
Provider Name (Legal Business Name): DIANE ELAINE BERGMAN PETERSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 CENTRAL PARK DRIVE #209
STEAMBOAT SPRINGS CO
80487
US

IV. Provider business mailing address

940 CENTRAL PARK DRIVE #209
STEAMBOAT SPRINGS CO
80487
US

V. Phone/Fax

Practice location:
  • Phone: 970-879-3738
  • Fax: 970-870-6441
Mailing address:
  • Phone: 970-879-3738
  • Fax: 970-870-6441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number30507
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number46731
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: