Provider Demographics
NPI:1992707160
Name:PETERSON, RAYMOND WILLIAM JR (DPM)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:WILLIAM
Last Name:PETERSON
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6701 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-5110
Mailing Address - Country:US
Mailing Address - Phone:520-747-1435
Mailing Address - Fax:520-747-1435
Practice Address - Street 1:6701 E 22ND ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-5110
Practice Address - Country:US
Practice Address - Phone:520-747-1435
Practice Address - Fax:520-747-1435
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0074213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4123720001Medicare NSC
AZT42033Medicare UPIN