1033281019 NPI number — DR. KELSEY CARL PETERSON JR. M.D.

Table of content: DR. KELSEY CARL PETERSON JR. M.D. (NPI 1033281019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033281019 NPI number — DR. KELSEY CARL PETERSON JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
KELSEY
Provider Middle Name:
CARL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033281019
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20462 KENWORTH CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92646-5446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-329-0179
Provider Business Mailing Address Fax Number:
714-965-0311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17742 BEACH BLVD
Provider Second Line Business Practice Location Address:
245
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92647-6818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-329-0179
Provider Business Practice Location Address Fax Number:
714-965-0311
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G17592 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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