Provider Demographics
NPI:1285674317
Name:PETERSEN, WILLIAM C (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:PETERSEN
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:PO BOX 79137
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0137
Mailing Address - Country:US
Mailing Address - Phone:757-668-7200
Mailing Address - Fax:757-668-9691
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-7320
Practice Address - Fax:757-668-9735
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036098207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017368930001Medicaid
WV1840707000Medicaid
MD633236600Medicaid
VA005709733Medicaid
DE1000035696Medicaid
NC8905209Medicaid
DE1000035696Medicaid
VA050001278Medicare ID - Type Unspecified