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General NPI Number Information
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NPI Number | 1194862433
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Entity Type | Individual
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Provider Name | TIMOTHY JOHN PETERSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/30/2007
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Last Update Date | 04/02/2009
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Provider Practice Location Address
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Address Line | 3141 N 3RD AVE SUITE 100
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City | PHOENIX
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State | AZ
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Zip | 85013-4351
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Country | US
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Telephone | 602-331-5174
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Fax | 602-745-7950
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Provider Business Mailing Address
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Address Line | 2540 N AVENIDA SORGO
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City | TUCSON
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State | AZ
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Zip | 85749-8113
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Country | US
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Telephone | 520-760-8895
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Fax |
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 15942
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 20764
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 22229
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License Number State | MN
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