1750536611 NPI number — DENA PETERSEN, M.D. P.C

Table of content: (NPI 1750536611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750536611 NPI number — DENA PETERSEN, M.D. P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENA PETERSEN, M.D. P.C
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:
1750536611
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4574 N 1ST AVE STE 180
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85718-5699
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-293-1415
Provider Business Mailing Address Fax Number:
520-293-1434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4574 N 1ST AVE STE 180
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85718-5699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-293-1415
Provider Business Practice Location Address Fax Number:
520-293-1434
Provider Enumeration Date:
11/19/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PETERSEN
Authorized Official First Name:
DENA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
520-293-1415

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10296 . This is a "PREPCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: AZ0817530 . This is a "BLUE CROSS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: Z20625 . This is a "MEDICARE ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 0100823 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9778467 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".