Healthcare Provider Details

I. General information

NPI: 1033310677
Provider Name (Legal Business Name): SOPHIE PETERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 06/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 PAN AMERICAN FREEWAY STE 450
ALBUQUERQUE NM
87109-3460
US

IV. Provider business mailing address

6100 PAN AMERICAN FREEWAY STE 450
ALBUQUERQUE NM
87109-3460
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-8787
  • Fax: 505-823-8788
Mailing address:
  • Phone: 505-823-8787
  • Fax: 505-823-8788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA117255
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD20120713
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: