Basic Information
| Provider Information | |||||||||
| NPI: | 1386640548 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | BAILEY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 197 CARNATION AVE | ||||||||
| Address2: | |||||||||
| City: | IMPERIAL BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919321007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194234972 | ||||||||
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| Practice Location | |||||||||
| Address1: | 34800 BOB WILSON DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921341098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195327577 | ||||||||
| FaxNumber: | 6195327673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | G83455 | CA | X | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | G83455 | CA | X | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
No ID Information.