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General NPI Number Information
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NPI Number | 1073571295
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Entity Type | Individual
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Provider Name | SAMUEL R PETERSON MD
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Gender | Male
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Dates
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Enumeration Date | 05/04/2006
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Last Update Date | 01/19/2023
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Provider Practice Location Address
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Address Line | 360 SAN MIGUEL DR STE 309
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City | NEWPORT BEACH
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State | CA
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Zip | 92660-7829
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Country | US
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Telephone | 949-640-0434
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Fax |
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Provider Business Mailing Address
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Address Line | 600 CORPORATE DR STE 100
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City | LADERA RANCH
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State | CA
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Zip | 92694-2107
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Country | US
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Telephone | 949-388-8022
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Fax | 949-388-8033
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 52631431205
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | C148028
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License Number State | CA
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