Provider Demographics
NPI:1215151113
Name:JOHN P PETERSEN MD PA
Entity type:Organization
Organization Name:JOHN P PETERSEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-794-3333
Mailing Address - Street 1:PO BOX 100013
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0013
Mailing Address - Country:US
Mailing Address - Phone:770-693-5818
Mailing Address - Fax:770-693-5821
Practice Address - Street 1:3555 10TH CT
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5013
Practice Address - Country:US
Practice Address - Phone:772-794-3333
Practice Address - Fax:772-569-6949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL920004346OtherRAILROAD MEDICARE
FL374792100Medicaid
FL23453AMedicare PIN