1184015380 NPI number — KENNETH PERCY PETERSON, MD, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184015380 NPI number — KENNETH PERCY PETERSON, MD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH PERCY PETERSON, MD, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1184015380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12155 MESQUITE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92344-7903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-796-4595
Provider Business Mailing Address Fax Number:
760-662-5711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16850 BEAR VALLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92395-5794
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-241-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSON
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
PERCY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-796-4595

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  C50553 , 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)





Copyright © 2007-2026 www.npivalidator.com