Provider Demographics
NPI:1316943129
Name:PETERS, TODD W (MD)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:W
Last Name:PETERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:15785 LAGUNA CANYON RD STE 125
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3140
Mailing Address - Country:US
Mailing Address - Phone:949-383-4190
Mailing Address - Fax:949-383-4183
Practice Address - Street 1:15785 LAGUNA CANYON RD STE 125
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3140
Practice Address - Country:US
Practice Address - Phone:949-383-4190
Practice Address - Fax:949-383-4183
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39517207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO465508Medicare ID - Type Unspecified
COG86531Medicare UPIN