Provider Demographics
NPI:1174948012
Name:PETERSON, JUSTIN ROSS (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROSS
Last Name:PETERSON
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 1:15301 WARREN SHINGLE RD.
Mailing Address - Street 2:
Mailing Address - City:BEALE AFB
Mailing Address - State:CA
Mailing Address - Zip Code:95903
Mailing Address - Country:US
Mailing Address - Phone:530-634-4662
Mailing Address - Fax:
Practice Address - Street 1:15301 WARREN SHINGLE RD
Practice Address - Street 2:ATTN: KEN WINN, CREDENTIAL COORDINATOR
Practice Address - City:BEALE AFB
Practice Address - State:CA
Practice Address - Zip Code:95903
Practice Address - Country:US
Practice Address - Phone:530-634-4662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-01
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101259916207R00000X
CA154828207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine