Provider Demographics
NPI:1215913165
Name:PETERSON, FREDERICK (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 MINTON RD NW
Mailing Address - Street 2:STE104
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1975
Mailing Address - Country:US
Mailing Address - Phone:321-724-1172
Mailing Address - Fax:321-724-9024
Practice Address - Street 1:6100 MINTON RD NW
Practice Address - Street 2:STE104
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1975
Practice Address - Country:US
Practice Address - Phone:321-724-1172
Practice Address - Fax:321-724-9024
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME32196207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL080185086OtherRAILROAD MEDICARE
FL038494100Medicaid
FL5840654OtherAETNA
FL2830929OtherAETNA
FL200859OtherWELLCARE
FL62193OtherBLUE CROSS BLUE SHIELD
FL2049145010OtherCIGNA
D65313Medicare UPIN
FL038494100Medicaid