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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