Provider Demographics
NPI:1164495941
Name:PETERSON, JOHN ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANDREW
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15 FOUNDERS LN
Mailing Address - Street 2:STE 100
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-3924
Mailing Address - Country:US
Mailing Address - Phone:217-243-0300
Mailing Address - Fax:217-245-6527
Practice Address - Street 1:800 W STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1910
Practice Address - Country:US
Practice Address - Phone:217-243-9471
Practice Address - Fax:217-243-5359
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055264Medicaid
ILL72271Medicare ID - Type Unspecified
D93384Medicare UPIN