Provider Demographics
NPI:1225005937
Name:PETERSON, KIMBERLY A (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4112
Mailing Address - Country:US
Mailing Address - Phone:585-225-0410
Mailing Address - Fax:
Practice Address - Street 1:2350 RIDGEWAY AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4112
Practice Address - Country:US
Practice Address - Phone:585-225-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183819207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01713693Medicaid
NY110181479OtherRAILROAD MEDICARE
NY110181479Medicare PIN
NYF71400Medicare PIN
NYF42276Medicare UPIN