MEDICARE: PETALUMA VALLEY INTERNAL MEDICINE INC

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	207QA0505X	Adult Medicine Physician	G55098	CA

General Provider Information

NPI Number	:	1326089806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETALUMA VALLEY INTERNAL MEDICINE INC

Provider Business Mailing Address
First Line	:	1310 COMMERCE ST #B
Second Line	:
City	:	PETALUMA
State	:	CA
Zip	:	94954-1469
Country	:	US
Telephone Number	:	707-778-7862
Fax Number	:	707-778-0969

Provider Business Practice Location Address
First Line	:	1250 BROADWAY
Second Line	:
City	:	SONOMA
State	:	CA
Zip	:	95476-7500
Country	:	US
Telephone Number	:	707-262-6267
Fax Number	:	707-734-7766

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVID G STREETER
Credential	:	M.D.
Telephone Number	:	707-765-1070

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	12/12/2018

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