1912375254 NPI number — MR. ERIC JOSEPH PETERS SR.

Table of content: MR. ERIC JOSEPH PETERS SR. (NPI 1912375254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912375254 NPI number — MR. ERIC JOSEPH PETERS SR.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERS
Provider First Name:
ERIC
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
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:
1912375254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 SMITH RANCH ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN RAFAEL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-492-0818
Provider Business Mailing Address Fax Number:
415-492-0834

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
629 WILSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NOVATO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94947-3823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-492-0818
Provider Business Practice Location Address Fax Number:
415-492-0834
Provider Enumeration Date:
09/03/2015

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: 324500000X , with the licence number:  P0809051024 , 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)

  • Identifier: N5526983 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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