Provider Demographics
NPI:1164639274
Name:PETERSON, JOHN R DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN R
Middle Name:DOUGLAS
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 1:901 PATIENTS FIRST DR STE 3300
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4700
Mailing Address - Country:US
Mailing Address - Phone:636-239-7344
Mailing Address - Fax:
Practice Address - Street 1:901 PATIENTS FIRST DR STE 3300
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4700
Practice Address - Country:US
Practice Address - Phone:636-239-7344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35499207RG0100X
MO2016004841207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology