Healthcare Provider Details

I. General information

NPI: 1144289422
Provider Name (Legal Business Name): DANA PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 PAN AMERICAN FWY NE 100
ALBUQUERQUE NM
87109-3427
US

IV. Provider business mailing address

6100 PAN AMERICAN FWY NE 100
ALBUQUERQUE NM
87109-3427
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-1010
  • Fax: 505-797-4503
Mailing address:
  • Phone: 505-823-1010
  • Fax: 505-797-4503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number91285
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: