Provider Demographics
NPI:1427080894
Name:PETERSON, BRENT P (DO)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:P
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:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0550
Mailing Address - Country:US
Mailing Address - Phone:479-463-7775
Mailing Address - Fax:479-463-7864
Practice Address - Street 1:3336 N. FUTRALL DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-463-3000
Practice Address - Fax:479-463-3050
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003013356207T00000X
ARE-11020207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100641320AMedicaid
MOP00046311OtherRR MEDICARE
MO209001809Medicaid
NE280356Medicare PIN
MOP00046311OtherRR MEDICARE