Provider Demographics
NPI:1225105604
Name:PETERSEN, JOSEPH R
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:R
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JOSEPH
Other - Middle Name:
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1344 HILAND AVE STE A
Mailing Address - Street 2:P. O. BOX 1263
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-1564
Mailing Address - Country:US
Mailing Address - Phone:208-678-1138
Mailing Address - Fax:208-678-5833
Practice Address - Street 1:1344 HILAND AVE STE A
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1564
Practice Address - Country:US
Practice Address - Phone:208-678-1138
Practice Address - Fax:208-678-5833
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5283174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010003563OtherBLUE SHIELD PROVIDER NO.
IDC36979OtherDMBA
ID014917OtherSELECTCARE
IDI000490OtherTRICARE
ID74096OtherBLUE CROSS PROVIDER NUMBE
ID0791870001OtherMEDICARE DMERC
IDI000490OtherTRICARE
ID1119681Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ID74096OtherBLUE CROSS PROVIDER NUMBE