Provider Demographics
NPI:1043250640
Name:PETERSON, JON LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:LEE
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 1:0310 COUNTY ROAD 14
Mailing Address - Street 2:
Mailing Address - City:DEL NORTE
Mailing Address - State:CO
Mailing Address - Zip Code:81132-8719
Mailing Address - Country:US
Mailing Address - Phone:719-657-4102
Mailing Address - Fax:719-657-4106
Practice Address - Street 1:0310C COUNTY ROAD 14
Practice Address - Street 2:
Practice Address - City:DEL NORTE
Practice Address - State:CO
Practice Address - Zip Code:81132-8719
Practice Address - Country:US
Practice Address - Phone:719-657-4102
Practice Address - Fax:719-657-4106
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR-46755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO300686OtherMEDICARE ID-TYPE UNSPECIFIED
CO30126363Medicaid
CO30126363Medicaid