Provider Demographics
NPI:1316162647
Name:PETERSON, KENT LEE (DPM)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1206 ROLLING HILLS CIR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-6485
Mailing Address - Country:US
Mailing Address - Phone:928-710-0770
Mailing Address - Fax:928-445-3802
Practice Address - Street 1:919 12TH PL
Practice Address - Street 2:SUITE 10
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1433
Practice Address - Country:US
Practice Address - Phone:928-776-0770
Practice Address - Fax:928-776-8991
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0261213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT42032Medicare UPIN
AZ69928Medicare ID - Type Unspecified