MEDICARE: SOUTH DRIVE MEDICAL CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	G33788	CA
2	103TC0700X	Clinical Psychologist	PSY4724	CA

General Provider Information

NPI Number	:	1043248560
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH DRIVE MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	515 S DRIVE
Second Line	:	#15
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94040-4209
Country	:	US
Telephone Number	:	650-961-9430
Fax Number	:

Provider Business Practice Location Address
First Line	:	515 S DRIVE
Second Line	:	#15
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94040-4209
Country	:	US
Telephone Number	:	650-961-9430
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. KENNETH S PETERS
Credential	:	MD
Telephone Number	:	650-961-9430

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	09/11/2025

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Directions to “SOUTH DRIVE MEDICAL CLINIC ” Practice Location

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