Provider Demographics
NPI:1154404226
Name:PETERSON, JOHN M (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 BARRE ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-3508
Mailing Address - Country:US
Mailing Address - Phone:802-229-9418
Mailing Address - Fax:802-229-5619
Practice Address - Street 1:72 BARRE ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-3508
Practice Address - Country:US
Practice Address - Phone:802-229-9418
Practice Address - Fax:802-229-5619
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT032-0000291204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006153Medicaid
VT6153OtherBC/BS
VT6153OtherBC/BS
VTD77545Medicare UPIN