Provider Demographics
NPI:1699794735
Name:PETERSEN, JEFFREY (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4249
Mailing Address - Country:US
Mailing Address - Phone:760-291-6700
Mailing Address - Fax:760-728-9732
Practice Address - Street 1:1035 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3338
Practice Address - Country:US
Practice Address - Phone:760-291-6700
Practice Address - Fax:760-728-9732
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79786207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA79786AMedicare ID - Type Unspecified
CAH71354Medicare UPIN
CA080190135Medicare ID - Type UnspecifiedRAILROAD