Basic Information
| Provider Information | |||||||||
| NPI: | 1144287707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15910 VENTURA BLVD | ||||||||
| Address2: | SUITE 1502 | ||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914362802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187289877 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15910 VENTURA BLVD | ||||||||
| Address2: | SUITE 1502 | ||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914362802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187289877 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 04/01/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | C50553 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | G50553 | 01 | CA | STATE LICENSE NUMBER | OTHER |