Provider Demographics
NPI:1154369346
Name:PETERSON, DOLORES (MD)
Entity type:Individual
Prefix:DR
First Name:DOLORES
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:
Practice Address - Street 1:701 E MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3032
Practice Address - Country:US
Practice Address - Phone:856-727-0999
Practice Address - Fax:856-727-7997
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06096900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7270208Medicaid
NJG19765Medicare UPIN
NJ7270208Medicaid