Basic Information
| Provider Information | |||||||||
| NPI: | 1629075205 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | NILS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 EMERALD BAY RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961506207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305435648 | ||||||||
| FaxNumber: | 5305418723 | ||||||||
| Practice Location | |||||||||
| Address1: | 2130 LAKE TAHOE BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961506405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305413277 | ||||||||
| FaxNumber: | 5305416913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 08/11/2008 | ||||||||
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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 | 207Q00000X | G68046 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G680460 | 05 | CA | MEDICAID |