Glen W. Petersen, M.D.

Primary specialty

Pulmonary Disease PhysicianTaxonomy code 207RP1001X

License

A26004 Issued in CA

Practice address

411 30TH St
Suite 314
Oakland, CA 94609-3312

Phone

(510) 465-6800

Fax

(510) 268-0634

NPI assigned

Jun 13, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150156800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1452729600000",
    "number": "1467495986",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "411 30TH ST",
            "address_2": "SUITE 314",
            "city": "OAKLAND",
            "state": "CA",
            "postal_code": "946093312",
            "telephone_number": "510-841-0689",
            "fax_number": "510-841-8119"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "411 30TH ST",
            "address_2": "SUITE 314",
            "city": "OAKLAND",
            "state": "CA",
            "postal_code": "946093312",
            "telephone_number": "510-465-6800",
            "fax_number": "510-268-0634"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "GLEN",
        "middle_name": "W.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-13",
        "last_updated": "2016-01-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207RC0200X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Critical Care Medicine",
            "state": "CA",
            "license": "A26004",
            "primary": false
        },
        {
            "code": "207RP1001X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Pulmonary Disease",
            "state": "CA",
            "license": "A26004",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00A260040",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kathrina L Peters, PH.D.
• Kristin Ann Peters, D.C.
• Michael D Peters, PHD
• Zachary Allen Peters, DC
• Felisa Petersen
• Melanie Dianne Petersen
• Scott J. Petersen, MD
• Sidney Petersen, RN
• Audrey Lauren Peterson, D.D.S.
• Ayannah Nichole Peterson

• Pulmonary Disease Physician in Oakland, CA
• Providers in Oakland, CA by specialty
• Pulmonary Disease Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 14, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.