Provider Demographics
NPI:1972506442
Name:PETERSEN, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 BRIARWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-2639
Mailing Address - Country:US
Mailing Address - Phone:432-505-4145
Mailing Address - Fax:833-941-0864
Practice Address - Street 1:4705 BRIARWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-2639
Practice Address - Country:US
Practice Address - Phone:432-505-4145
Practice Address - Fax:833-941-0864
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74917207P00000X
TXQ0536207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G748653Medicare PIN
CAF87030Medicare UPIN
CA00G749170Medicare ID - Type Unspecified