Basic Information
| Provider Information | |||||||||
| NPI: | 1326089806 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PETALUMA VALLEY INTERNAL MEDICINE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1310 COMMERCE ST #B | ||||||||
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| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949541469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077787862 | ||||||||
| FaxNumber: | 7077780969 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SONOMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954767500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072626267 | ||||||||
| FaxNumber: | 7077347766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 12/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | STREETER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7077651070 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | G55098 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
No ID Information.