Provider Demographics
NPI:1831194471
Name:JENSEN, PETER J (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35631-0897
Mailing Address - Country:US
Mailing Address - Phone:256-349-5275
Mailing Address - Fax:256-349-5279
Practice Address - Street 1:2115 CLOYD BLVD
Practice Address - Street 2:SUITE 9
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-7512
Practice Address - Country:US
Practice Address - Phone:256-349-5275
Practice Address - Fax:256-349-5279
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003113110AMedicaid
AL529915120Medicaid
AL051553533Medicare PIN
GA003113110AMedicaid