Provider Demographics
NPI:1043248560
Name:SOUTH DRIVE MEDICAL CLINIC
Entity type:Organization
Organization Name:SOUTH DRIVE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-961-9430
Mailing Address - Street 1:515 S DRIVE
Mailing Address - Street 2:#15
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4209
Mailing Address - Country:US
Mailing Address - Phone:650-961-9430
Mailing Address - Fax:
Practice Address - Street 1:515 S DRIVE
Practice Address - Street 2:#15
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4209
Practice Address - Country:US
Practice Address - Phone:650-961-9430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4724103TC0700X
CAG33788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A45679Medicare UPIN
CAZZZ85022ZMedicare ID - Type Unspecified