Organization
DESERT VISTA ANESTHESIOLOGY MEDICAL GROUP, INC.
Active
Organization
DESERT VISTA ANESTHESIOLOGY MEDICAL GROUP, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KENNETH PERCY PETERSON M.D. (PRESIDENT)
(805) 796-4595
Entity
Organization
Contact information
Practice address
15248 11TH ST, VICTORVILLE, CA 92395-3704
(760) 245-8691
(760) 843-6050
Mailing address
225 S LAKE AVE, 535, PASADENA, CA 91101-3005
(626) 795-6596
(626) 795-8247
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GR0105710
—
CA
01
—
ZZZ50059Y
BLUE SHIELD
CA
Enumeration date
02/09/2007
Last updated
07/18/2008
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