Provider Demographics
NPI:1003387291
Name:RENE' A PETERSON, DPM LLC
Entity Type:Organization
Organization Name:RENE' A PETERSON, DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RENE'
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:302-541-0323
Mailing Address - Street 1:35202 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19967
Mailing Address - Country:US
Mailing Address - Phone:302-541-0323
Mailing Address - Fax:302-539-8736
Practice Address - Street 1:35202 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:MILLVILLE
Practice Address - State:DE
Practice Address - Zip Code:19967
Practice Address - Country:US
Practice Address - Phone:302-541-0323
Practice Address - Fax:302-539-8736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000957915Medicaid