Provider Demographics
NPI:1689230450
Name:PETERSON, NICHOLAS EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:EDWARD
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:428 S ROBERTSON BLVD APT 506
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-3287
Mailing Address - Country:US
Mailing Address - Phone:651-707-4042
Mailing Address - Fax:
Practice Address - Street 1:8530 WILSHIRE BLVD STE 250
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3113
Practice Address - Country:US
Practice Address - Phone:651-707-4042
Practice Address - Fax:651-666-1610
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA1853512081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine