Provider Demographics
NPI:1104815315
Name:PETERSON, KENNY J (MD)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PSC 76 BOX 7634
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96319
Mailing Address - Country:JP
Mailing Address - Phone:315-226-6150
Mailing Address - Fax:315-226-6271
Practice Address - Street 1:35 MDOS/SGOPO
Practice Address - Street 2:
Practice Address - City:MISAWA AB
Practice Address - State:AP
Practice Address - Zip Code:96319
Practice Address - Country:JP
Practice Address - Phone:315-226-6150
Practice Address - Fax:315-226-6271
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35-07-3341-P207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35-07-3341-POtherSTATE LICENSE