Provider Demographics
NPI:1023012408
Name:PETERSON, TODD VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:VICTOR
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 BALTUSROL DR
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17202-7038
Mailing Address - Country:US
Mailing Address - Phone:717-860-0890
Mailing Address - Fax:
Practice Address - Street 1:3208 BALTUSROL DR
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17202-7038
Practice Address - Country:US
Practice Address - Phone:717-860-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065733L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA25-1716306OtherHEALTHNET/TRICARE
PA50059950OtherCAPITAL BLUECROSS (EPIQ)
PA50085311OtherCAPITAL BLUECROSS (WH)
PA080135921OtherRAILROAD MEDICARE
PA2134441OtherAETNA HMO
PA25-1716306OtherINTERGROUP
PA25-1716306OtherGREATWEST HEALTHCARE
PA25-1716306OtherDEVON
PA1007307260034OtherMEDICAID GROUP #
PA25-1716306OtherINFORMED
PA426611OtherHEALTH AMERICA
PA5957727OtherAETNA NON-HMO
PAPE085826OtherHIGHMARK BLUESHIELD
PA0017392500005Medicaid
PA120420420OtherDEPT OF LABOR
PA122865OtherUNISON
PA867633OtherMEDICARE GROUP #
PAG920-0027/KDM4POOtherCAREFIRST
PA25-1716306OtherSOUTH CENTRAL PREFERRED
PAMD065733LOtherLICENSE
PA001739250 0007Medicaid
PA2117289OtherMAMSI
PA25-1716306OtherMULTIPLAN/PHCS
PA2160082OtherFIRST HEALTH
PABP6106026OtherDEA
PA25-1716306OtherINTERGROUP
PA001739250 0007Medicaid