Provider Demographics
NPI:1184662058
Name:PETERS, JEANINE A (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEANINE
Middle Name:A
Last Name:PETERS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40450
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-0450
Mailing Address - Country:US
Mailing Address - Phone:440-871-4700
Mailing Address - Fax:440-871-4702
Practice Address - Street 1:26932 SOUTHWOOD LN
Practice Address - Street 2:
Practice Address - City:OLMSTED FALLS
Practice Address - State:OH
Practice Address - Zip Code:44138-1157
Practice Address - Country:US
Practice Address - Phone:440-427-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-3081-P213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH480027126OtherMEDICARE RAILROAD PIN
OH2103191Medicaid
OH480027126OtherMEDICARE RAILROAD PIN
OHU73079Medicare UPIN